Gender-based violence and HIV across the life course: adopting a sexual rights framework to include older women

Abstract

It is widely known that older women are at lesser risk for sexual violence than younger women, but current inattention to older women in the gender-based violence (GBV) field has minimized the experiences of older women survivors at great detriment to their health and rights. For example, health providers seldom ask older women about their sexual activity and relationships, a neglect that leads to older women being excluded from necessary HIV testing and care as well as support services for abuse. This oversight is increasingly worrisome given the rise in new HIV infections among adults age 50 and older in recent years, with the majority of transmissions stemming from individuals unaware of their HIV-positive status. Building on sexual rights scholarship, this paper argues for an approach to public health interventions for GBV and HIV that acknowledges older women – their sexuality, sexual agency, and activity – so that health providers and advocates acknowledge and serve older survivors.

Résumé

Il est bien connu que les femmes âgées risquent moins de subir des violences sexuelles que les jeunes, mais le manque d’attention accordée actuellement aux femmes mûres dans le domaine de la violence sexiste a minimisé les expériences des victimes âgées aux dépens de leur santé et leurs droits. Ainsi, les prestataires de santé questionnent rarement ces femmes sur leur activité sexuelle et leurs relations, un oubli qui les exclut du dépistage et des soins requis du VIH ainsi que des services de soutien en cas de violence. Cette omission est de plus en plus inquiétante, compte tenu de l’augmentation ces dernières années des nouvelles infections par le VIH chez les adultes de plus de 50 ans, la majorité des transmissions provenant d’individus ignorant leur séropositivité. Se fondant sur les connaissances en matière de droits sexuels, cet article préconise une approche des interventions de santé publique pour la violence sexiste et le VIH/sida qui tienne compte des femmes âgées – leur sexualité, leur activité et la maîtrise de leur sexualité – afin que les prestataires de santé et les activistes prennent en compte les victimes âgées.

Resumen

Es muy conocido que las mujeres adultas corren menos riesgo de sufrir violencia sexual que las jóvenes, pero la falta de atención a las mujeres adultas en el campo de la violencia de género (VG) ha minimizado las experiencias de las mujeres adultas sobrevivientes en gran detrimento de su salud y sus derechos. Por ejemplo, los profesionales de la salud rara vez les preguntan a las mujeres adultas acerca de su actividad y relaciones sexuales, un descuido que lleva a que las mujeres adultas sean excluidas de pruebas y tratamiento del VIH, así como de servicios de apoyo por maltrato. Este descuido es cada vez más preocupante dado el aumento en años recientes en nuevas infecciones por VIH entre adultos de 50 años de edad o más, con la mayoría de las transmisiones surgiendo de personas que desconocen su estatus VIH-positivo. Basado en una beca de derechos sexuales, este artículo argumenta a favor de un enfoque en intervenciones de salud pública para combatir la VG y el VIH/SIDA, que reconoce a las mujeres adultas, su sexualidad, agencia y actividad sexual, de manera que los profesionales de la salud y promotores reconozcan y atiendan a sobrevivientes adultas.

Key words:

• older women
• sexual rights
• gender-based violence
• HIV/AIDS
• global public health

Introduction

The field of international development has made significant progress in linking women’s health programming with resources for addressing gender-based violence (GBV)^*, but the majority of these efforts are directed towards women and girls of reproductive age.² Recognizing the critical link between sexual coercion, cultural norms tolerating violence against women, and HIV risk, advocates in this field have successfully urged for HIV public health interventions to complement, and in many cases integrate, programs to prevent and respond to GBV. For example, the United States’ President’s Emergency Plan for AIDS Relief (PEPFAR) launched the DREAMS^† partnership in late 2014: a 210-million dollar investment combining evidence-based programs for GBV and HIV interventions for young women and adolescent girls aged 15–24.³ Responding to the urgency of the global HIV epidemic, the DREAMS partnership and other similar programs provide a critical investment where risk is shown to be the highest.

Despite their lesser risk of sexual violence and HIV, older women are not immune to violence or HIV transmission. On the contrary, research has shown that older women who experience physical or sexual assault face more severe health consequences than younger women, resulting in their greater health service utilization, declines in overall health status, and poorer life expectancy.⁴ Problematically, because most data collected on GBV and HIV prevalence stops counting women once they reach 50, there is still much we do not know about the extent of violence in the lives of older women and their unique risk factors for HIV.⁵ Therefore, it seems that older women are virtually absent in this segment of the global public health agenda – a serious oversight considering that women age 50 and above comprise more than one-fifth of the global female population.⁶ Meanwhile, our world continues to age rapidly. By 2030, there will be 1.375 billion people over the age of 60; today and in the future, women are the majority of the older population, mostly living in developing countries.⁶ Ageing, therefore, is a gender issue, and older women must be fully included in the global public health agenda to prevent and respond to GBV and HIV.

Building on sexual rights scholarship, we argue for an approach to public health interventions for GBV and HIV that includes older women – recognizing their sexuality, sexual agency, and activity – so that health providers and survivor advocates acknowledge and serve women past reproductive age. By distinguishing sexual activity from reproductive capacity, a sexual rights approach to women’s health and human rights best facilitates the inclusion of older women. Complementing existing human rights law and international conventions, sexual rights augment human rights related to reproductive health by enshrining a right to pleasure, sexual orientation, sexuality, bodily integrity, and gender identity within the human rights framework.

The invisibility of older women in GBV research and programming targeting the intersection of violence with HIV is predicated on assumptions that as women age, their risk for sexual and physical assault from an intimate partner markedly decreases. This consensus has driven research, policy, and programs for GBV to be targeted towards younger women, and it has also given the impression that older women, by comparison, experience insignificant rates of abuse.² Complicating efforts to intentionally assess violence across the life course is a lack of agreement on how to define ‘old’ age. The precise definition of an ‘older woman’ is loose, ranging anywhere from over the age of 45 to over the age of 65.² In the absence of global consensus for a life course approach to GBV that would include older women, the international development field has relied on a standard for data collection that specifies when to stop counting individuals based on age. The Demographic Health Surveys (DHS) conducted by the US Agency for International Development (USAID), which are used to inform the aid allocations of many NGOs and donor countries, originated as a maternal and child health-focused survey used for family planning.⁵ As such, it was developed to be conducted among people between the ages of 15 and 49. Over time, new sections and questions have been added to the surveys, including the assessment of GBV and HIV prevalence, and women’s empowerment; however, the surveys continue to restrict the sampling frame to women below the age of 50.⁵ Despite recent changes and additions, USAID’s DHS continues to exclude women beyond reproductive age, making their needs invisible to donors when they make decisions on where and how to direct development funds.

The conflation of women’s health with reproductive health: why we need a sexual rights approach

Normative considerations governing who warrants inclusion in the DHS are inextricably linked to the data-driven explanation for why older women are effectively absent in the global public health agenda. Feminist scholars have long argued that society’s valuation of women is dependent on their ability to bear children, denying women’s sexuality beyond the scope of reproduction.⁷ In the field of international development, reproductive health has been an important driver in programming for women; once women age out of their reproductive capacities, however, they appear to become a forgotten population. As demonstrated by the DHS, women who are deemed ‘too old’ to bear children are discounted in global data collection informing investments in GBV and HIV programming. Accordingly, global public health programs for women remain predicated on a view of women’s roles as mothers, conflating women’s health in general with reproductive health in particular. Sexual rights scholars identify this problem in critiquing frameworks for women’s human rights that fail to distinguish sexual health from childbearing.⁸ When women’s health and human rights are dominated by a discourse centered on reproductive capacity, women who fall outside the scope of bearing children – either by choice or circumstance – are not protected; this is particularly acute for women as they age.

Decoupling sexuality from reproduction would undo the traditional valuation of women as child bearers, and resistance by governments and international bodies to recognize sexual rights reinforces the historic subordination of women. Rosalind Petchesky describes this resistance in action at both the 1994 International Conference on Population and Development (ICPD) in Cairo and the 1995 Fourth UN World Conference on Women in Beijing.⁸ Chronicling how delegates to both conferences struggled to agree on how to articulate women’s rights as human rights, Petchesky argues that affirmative entitlements to sexual pleasure were rejected in place of a negative approach to rights that specified freedom from abuse, violence, and coercion.⁸ The reason for what she characterizes as an aversion to sexual rights is rooted in taboos against homosexuality, bisexuality, and alternative family forms; in other words, sexual activity and identity not based on reproductive need.⁸ Permitting women to engage in sexual activity for purposes other than reproduction serves as a reminder that women are involved in intimate relationships throughout their life course. Likewise, acknowledging women’s capacity for sexual intimacy in older age identifies their risk for GBV and sexually-transmitted diseases such as HIV, in a way that the prevailing conflation of female sexuality with reproduction does not.

Making progress towards the realization of sexual rights for older women

While an international consensus on what constitutes sexual rights is yet to be formalized, there has been much progress towards a definition over the past thirty years. The Montevideo Consensus on Population and Development, the Asian and Pacific Declaration of Population and Development, the Vienna Declaration and Programme of Action, ICPD, the Beijing Platform of Action, and the Yogyakarta Principles have all taken steps towards defining sexual rights.⁹ Today, the 2014 Declaration of Sexual Rights by the World Association for Sexual Health (WAS) represents the standard advanced by sexual rights advocates.¹⁰ Though it has yet to be formally recognized by official multilateral bodies, the 2014 WAS Declaration promoted by advocates reaffirms the right to pleasure.¹⁰ Additionally, it updates the proclamation developed by WAS advocates at the 1997 World Congress of Sexuality in Vienna by underscoring sixteen specific sexual rights, including: the right to equality and non-discrimination (including based on age); the freedom from all forms of violence; the right to enjoy the benefits of scientific progress; and the right to access justice, remedies and redress.¹⁰

The evolution of sexual rights advocacy shows promise towards undoing the conflation of maternal health with women’s health and allows for an exploration of older women’s rights to sexual pleasure. Scholarship by Jennifer Oriel predates the progress made in the 2014 WAS Declaration and highlights the importance of advancing a specifically female right to sexual pleasure.¹¹ Arguing that historic sexual rights discourse based definitions of ‘legitimate’ sexual activity on the gratification of male desire, Oriel calls for a new approach to sexual rights that acknowledges how sexual pleasure could be experienced differently between women and men.¹¹ With its emphasis on inclusivity, the 2014 WAS Declaration responds to Oriel’s concerns and promotes an understanding of sexual rights that accounts for differences in gender identity, expression, and bodily diversity.¹⁰ These developments in the global sexual rights framework provide a clear pathway for the inclusion of older women, as “differences in gender identity, expression, and bodily diversity” should account for the intersections of ageing and gender on sexual behavior.¹⁰

Implementation of sexual rights: GBV and HIV in older women

The adoption of a sexual rights framework grounded in pleasure independent from reproduction contributes to improving our understanding of and response to GBV across the life course, including an awareness of the risks for women of all ages for HIV acquisition. Though older adults are not the main demographic of new HIV infections, sexually active older women remain at risk, particularly when considering that HIV transmission through heterosexual sex is the primary means of infection for women of all ages.¹² Since women are twice as likely as men to contract HIV in this way, health providers must possess an awareness of women’s engagement in sexual activity for pleasure past their years of reproduction.¹² Yet, in order for providers to recognize that older women are equally entitled to resources for HIV and GBV, older women must be seen as sexual agents. Entrenched cultural bias against recognizing independent female sexuality, coupled with assumptions that older women are not sexually active, prevent understanding how older women are at risk for relationship violence or HIV; this oversight has translated into a paucity of data, discouraging investment in age and gender responsive programs. As Gayle Rubin notes in “Thinking Sex,” there are politics within the realm of sexuality, with some types of sex being prioritized and accepted over other forms.¹³ The neglect of programming and policy around older women’s sexual lives cements elder sex in a less politically powerful position.

Feminist critiques of dominant approaches to HIV prevention offer additional insight into how the denial of older women’s sexuality negatively impacts their health. Cautioning that emphasis on condom use as the primary means of HIV prevention reinforces male entitlement to sexual pleasure, Oriel and others link women’s vulnerability to HIV with their sexual objectification by men.¹¹ Older women, however, are disenfranchised within the politics of sexuality, impeding their recognition as sexual agents, capable of eliciting desire. As a result, providers seldom consider older women as being in need of HIV testing. This oversight is increasingly worrisome given the rise in new HIV infections among adults age 50 and older in recent years, with the majority of transmissions stemming from individuals unaware of their HIV-positive status.¹² Older women are uniquely at risk of not knowing whether or not they have HIV, as they are extremely unlikely to ask for an HIV test without first being prompted by a provider.¹⁴ Low awareness levels in women over the age of 49 are linked with added risk for HIV transmission as highlighted in a 2014 report by UNAIDS.¹² In South Africa, for example, the HIV prevalence for women between the ages of 55 and 59 is nearly twice that of men in the same age group.^{12 ‡}

Oriel’s argument that male sexual privilege is intertwined with women’s HIV risk is additionally relevant for older women as she cites common resistance (or outright refusal) from men to wear condoms.¹¹ This risk can be magnified for sexually active older women, whose male partners are less likely to prioritize condom use because pregnancy is no longer a concern; further, gender norms influencing older women’s comfort and familiarity with open discussion of sexual behavior, or assertiveness in relationships, can contribute to a difficulty for older women to negotiate condom use with their partners.¹⁴ Scholarship documenting the impact of generational factors on older women’s reluctance to seek help for or disclose relationship violence sheds additional light on how sexual coercion adds to older women’s HIV risk. Widespread social expectations of privacy in family matters, the subservience of wives to their husbands, the acceptability of violence to maintain household order, and stigma against divorce have been shown to hinder older women’s ability to challenge or report abuse, or to seek help from a service provider.¹⁵ These social norms can also serve to discourage older women from requesting a reluctant male partner to wear a condom.¹⁴

Without distinguishing sexual rights from reproduction, policies building on the prevailing discourse for women’s human rights are limited in what they can accomplish for the advancement of women’s health and wellbeing – particularly for older women. As Petchesky notes, rights claims that focus solely on preventing sexual violence and promoting reproductive health, as opposed to upholding women’s right to sexual pleasure, fall short of appreciating the diversity of women’s sexual experiences independent from heterosexual intercourse for the purpose of bearing children.⁸ In addition to obscuring recognition of older women’s sexual agency, such a focus implicitly denies a place for older women in the GBV field. This manifests in the disbelief of older women who report GBV, and in a lack of recognition of signs of abuse by health providers and victim advocates, both of which contribute to an already underreported prevalence of violence, given the documented tendencies of older women to hesitate to disclose abuse.¹⁶

Fueling ageist assumptions that older women are not engaged in sexual activity (and thus not at risk for sexual violence) is the complicated matter of (actual or perceived) cognitive decline and dementia impacting providers’ perceptions of the veracity behind disclosures of sexual assault. Conversations with a geriatrician specializing in abuse among older adults reveals several cases in which female patients in their nineties presented with severe labial bruising, only to be dismissed as accidental injuries by a sexual assault nurse examiner (Dr. Laura Mosqueda, Professor and Director, University of Southern California Keck School of Medicine and National Center on Elder Abuse, personal communication, May 19, 2015). According to Dr. Mosqueda, it is not uncommon for health professionals working with older adults to accept alternative explanations for injuries that would be clearly attributed to sexual trauma among younger patients (ibid). While there is consensus in the sexual rights field that violence from an intimate partner is a clear violation not only of one’s right to be free from violence and abuse, but also of one’s right to sexual pleasure, less has been discussed regarding the rights of survivors who have experienced sexual abuse. We argue that essential to the right to sexual pleasure and freedom from violence is the right to support for all survivors – regardless of age – who disclose abuse, rather than denying their experiences. The routine invisibility of older women in the field of GBV underscores the importance of an inclusive life course approach to the provision of support services for all survivors as part of an overarching package of sexual rights.

Conclusion

While the near absence of older women in the global public health agenda for GBV and HIV reveals that the actualization of women’s sexual rights remains incomplete, progress is being made. In 2014, the World Health Assembly (WHA) passed a resolution to strengthen the role of the health sector in addressing violence against women, and regional consultations to draft a global plan of action for the resolution have advanced a life course approach to violence that recognizes women of all ages.¹⁷ Though not grounded in a sexual rights framework, the WHA resolution complements the 2014 WAS Declaration’s call for non-discrimination on the basis of age. This understanding of the fundamental link between gender, age, and health is needed for the inclusion of older women within broader programming and policy for women’s health.

The evolution of sexual rights over the past thirty years has been impressive. Petchesky, Oriel, and others first raised arguments that protection for women’s health and autonomy are inadequate without recognition of sexual rights, including the right to sexual pleasure. With time, advocacy for sexual rights has become more nuanced, and therefore more inclusive, expanding an appreciation for how sex, sexuality, and gender interact to influence a person’s sexual agency. By embracing the diversity of women’s sexual identities and experiences, today’s sexual rights platform intentionally includes older women. Recently, the United States Government made historic movement towards the advancement of sexual rights in a statement to UN Women on September 15, 2015, noting that although sexual rights are not human rights enshrined in international law, the U.S. will now begin using the term “sexual rights” to express its support for the rights and dignity of all individuals, “regardless of their sex, sexual orientation, or gender identity.”¹⁸ This change, while significant, will be limited to a symbolic shift in language until reflected in policy to promote sexual and reproductive health funding, programming, and research, for women and girls of all ages – regardless of reproductive capacity. Perhaps most critically, victim services and community health resources for GBV and HIV must be transformed to become equally gender and age-responsive.

Twenty years ago, delegates to the Fourth UN World Conference on Women in Beijing understood the intersection between gender disparities and ageing, and carved out a place for older women in their platform specifically referencing health and violence.¹⁹ Progress has stalled, largely driven to exclusionary data collection methods, which have overlooked the need for older women’s access to resources for programs related to GBV and HIV. This year, as the world commemorates the historic accomplishments made at Beijing in 1995, let us support women of all ages by renewing a commitment to protecting their health and rights beyond reproduction.

Notes

* We have adapted the World Health Organization (WHO) definition of ‘violence against women,’ which references both intimate partner and sexual violence, and cites the United Nations definition: "any act of gender-based violence that results in, or is likely to result in, physical, sexual or mental harm or suffering to women, including threats of such acts, coercion or arbitrary deprivation of liberty, whether occurring in public or in private life."¹ Recognizing the fluidity of gender and sexual identity, we employ the term GBV rather than ‘violence against women’ in order to be inclusive of the lives and experiences of intersex and trans women.

† DREAMS is an acronym for “Determined, Resilient, AIDS-free, Mentored, and Safe”.³

‡ 12% of women in South Africa ages 55–59, compared with 6.9% of men, are HIV-positive.¹²