|AIDS - 5 years since ICPD: Emerging issues and challenges for women, young people & infants. A UNAIDS discussion document (UNAIDS, 1999, 24 p.)|
What is gender?
Whereas sex is biological, gender is socially defined. Gender is what it means to be male or female, and how that defines a persons opportunities, roles, responsibilities and relationships.
A persons gender is one of the most powerful determinants of individual risk. Gender biases affect both sexes, and in a multitude of ways. In all its activities UNAIDS takes the broad definition of gender. However, our main focus here is on the risks and vulnerability associated with being female. The factors that put girls and women at special risk from HIV are both biological and social2.
2 Point of View: Women and AIDS, UNAIDS, Geneva, 1997
The risk of becoming infected with HIV during unprotected vaginal intercourse is two to four times higher for a woman than a man. Male-to-female transmission is more efficient because, during vaginal intercourse, a woman has a bigger surface area of mucosa (the membranes lining the genital tract) exposed to her partners sexual secretions than does a man. Furthermore, there is generally a higher concentration of HIV in semen than in the sexual secretions of a woman. Age is also important. The immature genital tract and scant vaginal secretions of young women put them at even greater risk than mature women because they provide less of a barrier to HIV. And there is evidence that the more fragile genital membranes and reduced vaginal secretions of postmenopausal women increase their vulnerability to HIV also.
Compounding womens biological vulnerability to HIV infection is a host of cultural, legal and economic factors that put them at special risk. In many societies girls face discrimination from birth onwards. Typically they have less access to education, information and skills training than boys, which handicaps them for life. As adults they have limited opportunity for employment; often no right to work or to own or inherit land and property in their own names; limited access, if any, to finance for their own business ventures; and often limited access to health care services. The low status of women makes them socially vulnerable to HIV, for all these discriminatory forces limit their opportunities to be informed about the functioning of their bodies, sexuality and health, and cripple their autonomy and power to protect themselves from infection.
In many cultures it is considered indecent for a woman to take the initiative in sexual encounters. Thus they are inhibited from seeking out information on HIV or procuring condoms themselves. And many women dare not bring up the subject of safer sex even with a regular partner for fear of a violent reaction or even abandonment by a man on whom they are totally dependent for survival. While in many societies infidelity in women is strictly and often violently censured, they are generally expected to tolerate infidelity in their menfolk even though, in the AIDS era, tolerance and silence may cost them their lives. A study from Pune, India, illustrates a situation common in very many societies. Of a sample of nearly 400 women attending the citys STI clinics, 93% were married and 91% had never had sex with anyone but their husbands. All of these women were infected with an STI and 13.6% tested positive for HIV.
Given the high social value placed on female chastity and monogamy, it is a paradox that for millions of girls and women across the world sex is the currency with which they are expected to pay for all lifes opportunities, from gaining admission to overcrowded classrooms to passing exams, securing employment or a market trading licence, or even crossing a border. In all these relationships women are dependent on and subordinate to men, and therefore in a weak bargaining position in the sex act.
There are approximately 960 million illiterate adults in the world, of whom two-thirds are women. Women own only 1% of the worlds land and receive 10% of its income.
If a woman is a reluctant partner, the risk of damage to the genital or anal mucosa is great, because of lack of lubrication and often rough handling by the male partner. The risk of infection with HIV is heightened too. Research confirms that non-consensual sex is a pervasive reality in girls and womens lives. In a study in Papua New Guinea, for example, half the young women questioned said they had been forced to have sex, often violently. A study in Malawi made very similar findings, and in Nigeria one young woman in five questioned by researchers reported coercion. Cultural practices such as female genital mutilation may also increase the risk of HIV transmission through trauma and tearing during sexual intercourse. Currently, according to UNFPA, some 130 million women worldwide are living with the consequences of this practice, and an estimated 2 million little girls are newly subjected to it each year.
Prostitution constitutes another situation in which women are unusually vulnerable to HIV infection, yet for multitudes of women without skills or resources, it offers the best opportunity for making a living. Sex workers may lack knowledge about HIV and how to protect themselves. But even if well informed they may find it hard to insist on safe sexual practices for fear of violence, or fear that an unwilling client will take his business elsewhere. Furthermore, prostitution is illegal in many places and simply carrying condoms can be taken by police as evidence of sex work. Prostitutions illegal status often drives it into the shadows and makes it hard to reach vulnerable people with lifesaving information and supplies. Among the most powerless and vulnerable people in the world are children and women coerced into the sex trade by traffickers, for they have multiple sex partners and no autonomy whatsoever. According to UNFPA, an estimated 2 million girls aged 5-15 may be coerced worldwide each year.
AIDS presents women with another dilemma in their sexual relationships. Safer sex - in particular the use of condoms - is incompatible with pregnancy, and those who want a child and yet who believe they are at risk of contracting HIV therefore face painful choices. In some societies a womans social status, and perhaps even survival, depends on bearing children, and where personal desire and social pressure coincide with very high levels of HIV infection, the choice for women is particularly cruel.
A gender-sensitive response
Since it was set up in 1996, UNAIDS has been committed to gender-sensitivity in all its policies and programmes, and to promoting awareness of the paramount importance of this among all players in the field. UNAIDS believes that a gender-sensitive response must take into consideration the factors that increase womens risk as well as their vulnerability. Often this calls for fundamental social change, including the empowerment of women at the household, community and national levels. A key objective must be to engage men as partners in social transformation. Furthermore, gender and AIDS need to become mainstream concerns in the programmes of governments and non-governmental organizations in all countries.
NEW TECHNOLOGIES HELP WOMEN PROTECT THEMSELVES
The female condom was launched in Switzerland in 1992, but it is only very recently that it has become widely available. Manufactured solely by the US-based Female Health Company, it is now marketed in more than 30 countries and over 4 million had been sold in the developing world by early 1998.
Consumer research throughout the world shows that it is acceptable to many, and that one of the commonest advantages cited by women is the personal control it gives them in the sex act. A woman can use it without discussion or active cooperation from her partner, and it can be put in place hours before intercourse, if desired, which means she can take steps to protect herself in unpredictable circumstances.
However the female condom is more expensive than the male condom, costing between US$2 and US$3 on the open market in developing countries, which puts it way beyond the means of the populations who could most benefit from it. UNAIDS has negotiated a special low price with the Female Health Company and has launched a major promotion campaign in developing countries with Population Services International. A variety of social marketing programmes are currently distributing male condoms with great success in the developing world, and their potential to distribute female condoms also at acceptable prices is being tested in a number of countries. There is a need for further advocacy at all levels to increase knowledge of and demand for female condoms. It must be noted though that the female condom will not change the balance of power between men and women in sexual relationships. In parallel, social marketing programmes of the female condom must work with women and men in the community to discuss and change gender-related inequalities.
Another product that would increase womens control in the sex act is a microbicide, a substance capable of killing HIV and micro-organisms that cause other STIs and that can be introduced into the vagina (or rectum) before sex. Unlike the female condom, which remains visible, a microbicide would ideally be invisible and odourless, hence undetectable by an uncooperative male partner. Despite the enormous need and potential for such products, the development of microbicides has been slow for a host of political and commercial reasons. Research is hampered, too, by the fact that scientists still have a poor understanding of how HIV is transmitted during sexual intercourse.
Nevertheless, in the years since Cairo, the number of microbicidal products under investigation has increased considerably, though there have been no breakthroughs as yet. The spermicidal agent nonoxynol-9 (N-9) looked promising in the laboratory, but proved not to be so in field trials recently concluded. However, there are at least two newly designed microbicides that could be ready for efficacy testing before the year 2000.
Since 1996, UNAIDS has served as Secretariat for the International Working Group on Microbicides, and acts as a strong advocate for microbicide research. It has published guidelines for the development of products that are intended to stimulate activity in the field.