Abstract
Despite the resources put into HIV education programmes with young people in sub-Saharan Africa in the past two decades, there is little clear evidence of impact. Many programmes continue to be oriented towards individual behaviour change (and in reality, often sexual abstinence) with insufficient focus on understanding how societies constrain or enable individual agency in sexual decision-making and how this is affected by social norms. If education programmes do address gender they often reinforce a “male perpetrator, female victim” discourse, where girls and women are held responsible for boys' and men's sexuality as well as their own. This paper discusses the discourses around gender, sexuality and HIV constructed by young women and men (aged 16–29) in a rural Eastern Zambia village. Data on young women's and men's narratives were gathered using a participatory peer approach. Research uncovered numerous and sometimes conflicting discourses (cultural, moral, economic, and sexual) influencing young women's and men's thinking about sexuality and sexual behaviour, in particular the limited possibilities for safe consensual sex, and thus their vulnerability to HIV. The research suggests that the realities young people face are much more complex than HIV prevention strategies address. We recommend a more nuanced approach, tailored to the community contexts involved.
Résumé
Malgré les ressources investies ces vingt dernières années dans les programmes d'éducation en matière de VIH pour les jeunes en Afrique subsaharienne, leur impact ne semble guère établi. Beaucoup de programmes demeurent orientés vers un changement de comportement individuel (et, en réalité, souvent l'abstinence sexuelle) et ne s'attachent pas suffisamment à comprendre comment les sociétés limitent ou autorisent la prise de décision sexuelle des individus et comment les normes sociales l'influencent. Si les programmes d'éducation abordent la sexospécificité, ils renforcent fréquemment un discours « un homme coupable, une femme victime », où les filles et les femmes sont jugées responsables de la sexualité des garçons et des hommes en plus de la leur. L'article analyse les discours autour de la sexospécificité, de la sexualité et du VIH construits par des jeunes femmes et hommes (âgés de 16 à 29 ans) dans un village de Zambie orientale. Les données sur les récits des jeunes femmes et hommes ont été recueillies par une approche participative reposant sur les pairs. La recherche a révélé des discours nombreux et souvent contradictoires (culturels, moraux, économiques et sexuels) influençant la pensée des jeunes femmes et hommes sur la sexualité et le comportement sexuel, en particulier les possibilités limitées de rapports sexuels consensuels sans risque, et donc leur vulnérabilité au VIH. La recherche semble montrer que les réalités que connaissent les jeunes sont beaucoup plus complexes que celles qui sont abordées par les stratégies de prévention du VIH. Nous recommandons une approche plus nuancée, adaptée aux contextes communautaires.
Resumen
Pese a los recursos asignados a los programas de educación sobre VIH para jóvenes en Ãfrica subsahariana en las últimas dos décadas, existe muy poca evidencia concreta del impacto. Muchos programas continúan orientados hacia el cambio de comportamiento personal (y en realidad, a menudo abstinencia sexual) con insuficiente enfoque en entender cómo las sociedades limitan o permiten la autonomía de cada persona en su toma de decisiones sexuales y cómo las normas sociales la afectan. Si los programas educativos tratan asuntos de género, a menudo refuerzan el discurso de “perpetrador masculino y víctima femenina”, donde a las niñas y mujeres se les imputa la responsabilidad de la sexualidad tanto de niños y hombres como la suya. En este artículo se tratan los discursos sobre género, sexualidad y VIH formulados por mujeres y hombres jóvenes (de 16 a 29 años de edad) en un poblado rural del este de Zambia. Los datos sobre las narraciones de las y los jóvenes se recolectaron utilizando un enfoque participativo de pares. Las investigaciones revelaron numerosos y a veces incongruentes discursos (culturales, morales, económicos y sexuales), que influyen en lo que piensa la juventud sobre la sexualidad y el comportamiento sexual, en particular las limitadas posibilidades de tener sexo consensual seguro y, por ende, su vulnerabilidad a contraer VIH. Las investigaciones indican que las realidades enfrentadas por jóvenes son mucho más complejas que lo abordado en las estrategias de prevención del VIH. Recomendamos un enfoque más matizado, adaptado para cada contexto comunitario.
Sexual relationships are hugely influenced by norms related to gender and sexuality within societies. In sub-Saharan Africa, the links between sexual violence, transactional and intergenerational sex, gender power dynamics in sexual relationships and HIV risk are well established.Citation1–8 This is reflected in data from Zambia which highlight asymmetries in between men and women in terms of money, power and age.Citation9,10 One in five women in Zambia has reported experiencing sexual violence, most commonly perpetrated by current or former husbands or partners.Citation9 Gender power imbalances are further reflected in a dual and often contradictory legal framework, with customary law – which most people marry under and which is better understood and more accessible than official systems. Sometimes customary law undermines freedoms granted to women through the constitution and plays a role in perpetuating norms.Citation11 There is no minimum age for marriage, except puberty, and one in five rural girls in Zambia marries before the age of 15.Citation9
Vast resources have been poured into youth-focused HIV education in sub-Saharan Africa, but there is little rigorous evidence so far of a clear impact of existing programmes in preventing HIV transmission and improving other sexual health outcomes.Citation12 Many programmes have an orientation toward information, education and communication and “behaviour change communication” approaches. They have been criticised in recent years for focusing on the individual and failing to take contextual factors such as gender power relations and economic and cultural factors into account, which influence individual behaviour.Citation13–16
There is increasing recognition at international level of the need for comprehensive sexuality education in schools that can reduce gender inequality, improve communication in relationships, increase self-awareness and self-efficacy in decision-making and seek to reduce sexual violence.Citation17 However, the actual movement of comprehensive sexuality education into national policy and practice has been slow and beset by many difficulties.Citation16 In Zambia there has been good progress in policy, with attention in the National HIV and AIDS Framework 2011–2015 to providing sexuality education and linking it to girls' empowerment, poverty reduction and cultural practices, as well as promoting condoms. However, there has been less success with implementation in schools, with only patchy training of teachers and infrequent delivery of lessons, given its low status as a non-examinable subject. In reality much HIV education depends on NGOs.Citation18 Many programmes end up falling into abstinence-focused messaging, particularly by faith-based organisations, resulting in condoms being stigmatised and associated with promiscuity. When gender is brought in, it may be in the form of warning girls to stay away from predatory men and boys and avoid getting into risky situations, reinforcing unhelpful gender norms and making girls responsible for boys' sexuality as well as their own, reinforcing a “male perpetrator–female victim” discourse.Citation18
This evidence points to the importance of social and structural determinants in sexual decision-making, which affect individual sexual behaviour among adolescents and young people. At the same time, there is little information on how decision-making and communication about sex play out, despite their importance in influencing sexual and reproductive health outcomes for young people. This study sought to understand how these interactions play out in a community in Zambia, a country with poor gender and sexual and reproductive health and rights outcomes. We do not attempt to provide an objective account of sexual behaviour, but to look at dominant discourses and social norms, their importance in young men and women's lives, and how they are navigated.
Methodology
The research was developed though a partnership with the International HIV/AIDS Alliance and one of their partner organisations, Young, Happy, Healthy and Safe (YHHS), and was carried out in 2008. YHHS operates in Chipata district, Eastern Province, Zambia. It promotes sexual and reproductive health and rights of young people through training and supporting teachers to deliver sexuality and life skills education in schools, running a community peer education programme and working with health services, local leadership and traditional initiation advisors.
YHHS identified Chitepe (name changed to preserve anonymity), a community they were working in, as the location for the research. Chitepe is a rural village situated a few miles from Chipata town on the Chipata–Lusaka main road. Christianity is the main religion in the village, which many combined with animist beliefs. The village has a health centre, primary and secondary school, sports playing field, a number of churches, a church-run training centre and a number of bars, small shops and market stalls. People in the area are mostly from the Ngoni ethnic group, with a small minority from the Chewa group. There is a lack of reliable local data on HIV prevalence but the village's position on the main road and near the border with Malawi make estimations of HIV prevalence high (Environmental Health technician, Chitepe Clinic, personal communication, October 2008). Agricultural work is the main source of income in this area. Men grow and sell crops, tend to livestock and undertake cross-border trading whilst women gain income through agricultural production, brewing and selling beer, and from boyfriends and older men. There are no local data regarding education, but data for the Eastern province show that both girls and boys have lower levels of schooling, with a bigger gender gap, than the national average.Citation9
We adopted an approach based on the Participatory Ethnographic Evaluation and Research (PEER) method.Footnote* This method does not attempt to collect “social facts” about people's behaviour or experience, but to understand the meanings they attribute to the behaviour of their peers and the contradictions and differences expressed by people within a social network.Citation19 Attempts at objectivity or aiming for representative samples are not goals within this research paradigm. In the PEER method the researchers are from the peer group that is being researched. In effect, these peer researchers act as key informants because of their recognised status as community members and their knowledge of the local context. We adapted the method to fit the resource and time constraints we had.
The second author, a volunteer with YHHS, joined the first author to facilitate the research process. We recruited three female and three male peer educators aged 19–24 from the YHHS programme to act as peer researchers. They were selected by YHHS for their good communication skills and ability to discuss issues around sex sensitively and non-judgementally. They participated in a three-day training and planning workshop facilitated by the authors. The workshop began by eliciting how issues around sex, gender and HIV affect young men and women in the community. Emerging themes were social networks and relationships, power and control, communication, and traditional practices and other influences (belief systems, common cultural practices, religion, parents, school, economics, modernity, media, using drugs and alcohol). The group developed a separate interview guide for each theme. Peer researchers were also trained in interview techniques and ethical standards, and translated the tools we developed into the local language. The research received ethical approval from the Institute of Development Studies, University of Sussex, and followed their Code of Practice for Research and PEER guidelines.Citation20
The field research concentrated on a population of young adults in the peer group, as defined by the peer researchers. In all, they interviewed 30 young people aged 16–29 years – 12 male, 18 female; 8 married, 22 unmarried; most out of school. Since the PEER approach uses informal peer networks to gather data, peer researchers were responsible for identifying people in their peer group and asking them to participate; we did not try to control this. The peer researchers interviewed each of the participants four times, once per theme. Each discussion took approximately one hour and took place in locations in the community outside of earshot of others but usually in public spaces. Male and female peer researchers only interviewed peers of the same sex as themselves. Data were collected over a ten-day period, during which we interviewed the peer researchers every two days. They recounted to us the different conversations they had had, and the first author took detailed notes. By probing them further, they gained more depth, which modelled interviewing techniques. This helped peer researchers develop their own interviewing and critical thinking skills and they were able to use them in subsequent interviews with their peers, bringing richer data the next time we met them. Sometimes the responses sparked off a discussion, which also provided rich data for the research. Feedback sessions also served as an important monitoring and support function: difficulties were discussed, reflected on and ironed out where possible.
To complement the data and analysis provided by the peer group the authors interviewed a few key influential figures in the community: a church leader, a representative from the clinic, and a male and female alangizi (traditional initiation advisers).
At the end of the fieldwork, a one-day feedback workshop took place. Peer researchers conducted their own analysis, in single sex groups, of the main findings, challenges and recommendations for their work, as did the authors, and we all shared these with YHHS programme staff, to consider implications for their work. This analysis became an important aspect of the research, reflected in the overall analysis. It also allowed YHHS to immediately consider and take forward activities emanating from the research. The peer researchers returned to their roles as peer educators having gained from this experience and their engagement in it.
Findings
The research highlighted the different discourses of gender and sexuality that young women and men constructed, which were often contradictory. These discourses came from cultural teachings, religion, economic realities and discussions of communication, desire and consent, which are described below. These both build on and complicate each other, highlighting the complexities and dilemmas for young people's sexual lives and health.
Cultural constructions of masculinity, femininity and sexuality
Young men and women in Chitepe often associated gender identities with power in relation to sexuality. For example, men were seen to have higher status, power and control because of an assumed innate physical and/or sexual strength or dominance, rather than understanding this as a product of society. This was also linked with the creation story in the Bible.
“Males have more power, as they are the ones who propose females.” (Male, aged 22)
“Males have more power because woman was made from the ribs of the man.” (Male, aged 20)
“Men, because it's nature. They buy everything at home and they have the power to initiate sex. It's related to the Bible scriptures - God made Adam before Eve and this shows that the woman is always following.” (Female, aged 23)
In Chitepe, as in much of Zambia, girls and boys go through an initiation process upon reaching puberty, where they are taught by alangizi. Girls are taught how to be women, undertake the role of homemaker and respect others in the community, and issues such as personal hygiene. They are also taught about how to please a man sexually, including using erotic dances to seduce men. There is a ceremony at the end of the process where girls show their dances. Young women said that this was a risky time for girls, who are vulnerable to sexual advances and forced and coerced into sex by men and boys. Girls are taught at a young age to be highly sexualised through these processes, but at the same time female virginity is prized, creating conflicting messages for girls. Young women said that it was common for girls to be given lunkhanko (a traditional medicine) upon reaching puberty as a method of preserving female chastity, and warned it would kill her if she had sex with more than one man in her life.
Meanwhile the initiation process for boys emphasises their new roles as men – to be hardworking, strong and a provider – and they are taught craftwork and leadership skills. Boys are taught that that their roles as men include being on top during sex and having sex three times a night. This frequency of sex was the most common description of what an ideal man can do that young men and women described during the research. They are given herbs which they associate with sexual arousal and potency, reinforced by being given herbs to put on their bodies whilst jumping on fire. Both young men and women considered this as increasing the potential for sexual violence, as men believed the herbs made them need sex immediately.
These processes highlight some of the contradictions within the cultural discourse, that simultaneously encourages girls to make themselves sexually desirable and available, desiring and assertive but also sexually passive and chaste, whilst boys learn about sexual need and dominance but within a framing of living up to expectations on “performance” that may be difficult to fulfil.
Religion and the moral discourse
Most young men and women said that they went to church, and they talked positively about what the church teaches them about sex, which is abstinence until marriage.
“We feel good about religion, as we are taught how we can change our behaviour from bad to good. We are taught how to change our traditional beliefs at church, for example that tyoli and chimwesho [traditional seductive dances] should only be done when you are ready for marriage.” (Female, aged 25)
“They feel good about the church as they are taught no sex before marriage. It makes them feel good to strive for that, even though it's not the reality.” (Female, aged 23)
“There is no difference between churchgoers and non-churchgoers in their real behaviour and character, or in what they do at home. The church says that when you have sex before marriage you will be judged as a sinner, but they do it anyway. Church is a place where many people hide their sins, whilst others think they'll be saved or healed.” (Male, aged 28)
Power, money and bargaining
Participants said that transactional sex was very common, and that this was a major risk factor for HIV. Men and women are socialised to see men as providers, and men saw this as a great source of pressure on them. Girls expected gifts or money from male partners, whatever the type of relationship, and this was an area where they had a relatively high level of control:
“It can be difficult when the girl needs money and the boy doesn't have any. Girls think boys are very strong, so can do any job, so should have money. If he can't provide in the relationship, the girl can dump him or start other relationships with other men.” (Male, aged 19)
“Females have power over males, like when they ask for something males must buy it to avoid their friendship stopping. A woman can refuse to wash her husband's clothes if he has not provided soap. Even if she is also working, the expectation is that he is the provider, so men have pressure on this.” (Male, aged 18)
“Women do use sex to keep control of things, like ‘You were supposed to bring me a gift’. Women sometimes withhold sex, like when they quarrel or to get their own way.” (Female, aged 22)
“Yes, they go to bars and sell their bodies – they get what they want. In an older man–young girl relationship she has more power, for example, by saying she doesn't want to go to the bush but wants to go to a guesthouse. If they are drinking beer together she can say ‘Let's go’ or ‘I don't want to - let's stay here’. But when they have sex the man has more power.” (Female, aged 19)
“Older men and young girls – she has more power in this relationship as she can end the relationship at any time and he fears that.” (Female, aged 21)
Discourses around desire and consent
Young men's and women's responses suggested that their reality in negotiating sex may be more complex than the “dominant male, passive female” HIV/AIDS discourse suggests. The peer researchers asked about the way men and women communicated with each other about sex. An emerging narrative was that men were more likely than women or girls to express what they wanted verbally. A woman verbally expressing desire was associated with promiscuity, but women talked about communicating desire in non-verbal ways. Men and women also talked about the way a girl is supposed to say no to sex, even if she wants it:
“He would negotiate, since in tradition saying no means accepting. He'd do this by using sweet and lovely words, like sweetheart, darling, princess. She would then accept as she knows he really loves her.” (Male, aged 28)
“A girl will say no even if she wants sex – she can't seem too eager or she will be seen as a prostitute. But they can tell by the way she talks and her actions that she's really interested.” (Female, aged 22)
“A man should ask the woman to have sex, not the other way around. Females don't make that decision, they just let it happen to please their partner (this happens in any relationship). However, when it happens women don't feel good. They feel they have been forced when they were not prepared.” (Female, aged 23).
Discussion
The analysis of the voices of young people in this study critiques oversimplified representations of male perpetrators and female victims. It demonstrates the complexity of sexual negotiation and decision-making, with both young men and young women exercising agency but within constraining gender and sexual norms linked to religion, and economic and cultural conditions. It also shows how young men and women often receive different and conflicting messages about appropriate sexual behaviour, but that normative ideas around masculinities and femininities were central to how these play out in practice.
We found that it was very common for women to have sex when they didn't want it, or before they were ready; thus, decision-making and communication around sex are a critical part of understanding HIV vulnerability.
A cross-cutting theme was the movement between control and vulnerability that appears across young people's narratives. For example, women in the study talked both of the subtle ways they were able to communicate what they wanted around sex, but also of a helplessness around sexual decision-making. They talked positively about enjoying sex, but often of how bad it felt to be forced. They gained a lot from the church, despite its seeming disapproval of the reality of many young people's lives. Many were able to use their femininity actively and to their advantage to gain materially from older men, and talked of many instances of standing up to their partners, but usually in ways that reinforced gender norms of “the male provider” which may ultimately disadvantage women and put them at risk of HIV. These conflicting messages make it very difficult for young women and young men to negotiate safer sex.
An unexpected outcome of the research was how the process opened up transformative possibilities for the peer researchers themselves. Young women in the research team tended not to be conscious of many of the contradictions and inequalities that surrounded them and put them at risk, whilst the young men were more likely to critique the conditions that influenced how sexuality was expressed. However, we saw an important change in the female peer researchers during the research process, during the facilitated discussions exposing and discussing the contradictions that appeared in their discourses. They began to question what they had previously taken for granted, which led at times to impassioned, angry and political responses, for example:
“We should visit the president, our MP, the councillor!”
“We should write letters – write to the radio stations and alangizi!”
“Will I open my legs for you? I'm tired! Why should I open my legs?!” (Female peer researchers)
The peer researchers undertook their own analysis of the data at the end, and whilst they did not necessarily identify all the nuances described in this paper, a consciousness of power in sexual and romantic relationships and of gender inequalities became a central part of their analysis. For example, their key findings included the importance of money (and the relationship with power) in relationships, how informal rules may make it difficult for women to express whether they want sex or not, and how many men would prefer to follow the rules of tradition rather than the church, as it may give them more power over sexual decision-making. They identified the importance of being aware of and engaging with different perspectives even within a peer group and of working with young people, alangizi, and church and traditional leaders to expose differences, create dialogue and develop strategies for change.
Whilst this research did not have a follow up planned to look at longer-term impact, the research experience does appear to have led to an increased emphasis in project activities on linking work with young people on sexual health explicitly with local understandings and values about gender roles and norms. It has also influenced the use of questioning approaches to pick apart and discuss what these mean with different groups in communities and what can be changed to make relationships safer for young people.
Conclusion
This research generated important learning for HIV education programmes. Firstly, paying attention to and learning about the discourses circulating about gender and sexuality in a given context is important, so that discussing and addressing these can be built into HIV programmes. In Chitepe it will be important to bring in those who influence the discourses (including traditional and religious leaders and initiation advisers) to discuss the contradictions with young people and how these affect sexual health. This dialogue needs to be facilitated with an awareness of power dynamics according to sex, age and community position, to ensure that all voices are heard.
Whilst unintended, this research modelled a change process, raising consciousness around gender inequalities and their relationship to consent and sexual rights for young people. These opportunities need to be nurtured by supporting young people to analyse gender and sexual norms that influence their sexual behaviour in other contexts, and consider what needs to be changed to ensure sex is wanted by both partners and make sex less risky. The PEER approach is a highly effective way to do this and can be seen as a tool for advocacy as well as research.
Further consideration is needed of how local understandings and discourses, including all their contradictions and complexities for young men and women, can be understood and integrated into HIV and sexuality education programmes. These approaches require a deep level of discussion, questioning and analysis to bring out different perspectives and critique norms and structures that influence assumptions and behaviours. Approaches such as this do not translate easily into an under-resourced education system with teachers who have not been trained in them. A carefully designed and systematically evaluated large-scale intervention that adopts the approaches used in this research within a school or community-based education programme would generate important knowledge on workable strategies. Some promising interventions include the Stepping Stones programmeCitation25 and Our Future series.Citation26 Stepping Stones is a community intervention training package that has been adapted for different contexts in Africa. Evaluations so far have shown an impact in some areas, such as attitudes to gender and sexual risk-taking, but not to actual HIV incidence.Citation27 Our Future was developed by the HIV/AIDS Alliance for schools in Zambia. Both programmes aim to include some critical reflection on gender and sexual norms, and this work could be extended further through developing facilitator training and materials to pay more attention to the contradictory discourses that circulate about gender and sexuality, how they affect sexual health and rights and how they can be negotiated.
Understandings around sexual consent need to be part of youth HIV education programmes, as do discussion and analysis by young people about gendered messages around sex and relationships that they receive from different parts of their lives (religion, culture, parents, friends). This study provides an illustration of how programmes that focus on individual behaviour change and transmission of knowledge will fail to have an impact and calls for the complex social realities young people face to be addressed across their societies.
Acknowledgements
We would like to acknowledge Young, Happy, Healthy and Safe, especially Zhikalo Phiri, for their full engagement and support in the fieldwork, and taking the findings forward in their work. The International HIV/AIDS Alliance Secretariat and Alliance Zambia provided financial, logistical and technical support for this study: In particular, Gill Gordon provided detailed guidance on study design, and Divya Bajpai and Shupe Makashinyi gave helpful feedback on the draft paper. Jerker Edstrom at the Institute of Development Studies provided supervision support and advice to the lead author on data analysis, and Jenny Parkes of the Institute of Education provided advice on the draft paper.
Notes
* Developed by Options Consulting and the Centre for Development Studies, Swansea http://www.options.co.uk/peer/
Related Research Data
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