Male Norms and HIV Risk Behaviors in Ethiopia

Male Norms and HIV Risk Behaviors in Ethiopia

(Literature Review)

Prepared By: Esete Getachew

Table of Contents

Background………………………………………………………………………………………………………
Definition of Terms……………………………………………………………………………………

Prevalent Male Gender Norms and Notions of Masculinity in Ethiopia and their impact on the spread of HIV………………………………………………………………………………………….

2.1 Male Dominance, Violence and Discrimination against Women…………………

2.2 Multiple Sexual Relationships as “Natural” to Men……………………………………….

2.3 Mobility, Men and HIV/AIDS………………………………………………………………………..

2.4 Men’s Alcohol and Substance Consumption Behavior……………………………………..

2.5 Men and their Health Service Seeking Behavior………………………………………………

3. Windows of Opportunity ………………………………………………………………………………………..

4. Overview of Projects on Male Norms in Ethiopia (Engender Health/Hiwote Ethiopia)…………………………………………………………………………………………………………………..

Acronymsand Abbreviations

AIDS Acquired Immune Deficiency Syndrome

BSS Behavioral Surveillance Survey

CSWs Commercial Sex Workers

DHS Demographic and Health Survey

HIV Human Immunodeficiency Virus

MHRC Miz-Hasab Research Center

OSY Out of School Youth

PMTCT Prevention of Mother to child Transmission

SNNPR Southern Nations, Nationalities and People’s Region

SRH Sexual and Reproductive Health

UN United Nations

VCT Voluntary Counseling and Testing

WHO World’s Health Organization

Glossary

Arada Cool

Chebsie The consumption of alcohol after chewing Khat

Kemite A woman who lives with a man without being married.

Khat A green leafed stimulant drug.

Wushema Secret Lover

Background

Cultural norms and social constructions of gender roles play important parts in determining how men and women behave and how they interact with each other. Societies portray them differently, which has strong influence on their individual behavior and power dynamics between the sexes. People’s control over their lives and choices arestrongly determined by gender-related values and norms defining men, women and their relationships. Prevailing ideologies of masculinity and femininityshapenot only personal sexual behaviors, but also their sexual interactions with one another, and effective HIV programs and policies must consider these gender norms and values.

In many instances, women are in a disadvantaged position and more vulnerable to HIV/AIDS. In Ethiopia, according to the single point HIV prevalence estimate in 2007, the level of HIV infection in all regions of the country is higher among women (2.8%) when compared to men accounting for 1.8%.This disparity is exacerbated by stereotypical gender roles, unequal power relations between men and women, women’s increased biological susceptibility as well as their increased economic and social vulnerability (ECA, 2004; WHO, 2003).

In response to this, programs/ HIV interventions have often focused primarily on empowering women.Relatively, the role of men has been largely disregarded and little attention has been given to the importanceof engaging men by addressing their issues, harmful male norms and masculinity. However, there is a growing consensus of the need for programs and policies that not only frame male involvement as a way to improve the lives of women, but also that explicitly address the needs of men and boys in their own right—addressing their sexual, reproductive, and other health needs.

Specifically targeting men and boys is critical to improve the sexual and reproductive health of both men and women while simultaneously challenging harmful gender norms and encouraging gender equality. In essence, effectively halting or reducing the spread of HIV globally will require increased discussions on the specific issues of men and constructions of masculinities.

Indeed there is little understanding and a lack of local evidence on the social construction of male gender norms in Ethiopia and what it means to be a “real” man for people living in different cultures of the country. A better understanding of these issues may help to tailor programs that address HIV and other health risks to the needs of males in the Ethiopian context. This literature review will critically review, the very limited local research available on this topic, as well as other international documentsproviding insight about the influence of social norms on men’s attitudes and behaviors so that these behaviors can be better understood and addressed in HIV prevention programming.

With this in mind, this paperfirst seeksto identify prevalent male gender norms and notions of masculinity throughout Ethiopia and their impact on the health of men and women. Specifically, this review explores possible linkages between social expectations attached to being a “real” man with the spread of HIV/AIDS in addition to discussing, how prevailing norms and views of manhood might contribute to risk behaviors (e.g. multiple sexual partnerships, alcohol use, sexual violence) and reinforce gender inequality. In the next sections, these ideas will be looked at in detail but before discussing how masculinities influence and drive men into risky behaviors, some definitions of terms prevalently used in gender literature are given below.

1.1Definitions of Terms

Gender refers to the social constructions of roles, expectations and definitions of what it means to be a man and a woman in a given context (Renzetti and Curran, 1995; WHO, 2003).

Sexrefers to biological characteristics that can be used to distinguish between a male and a female (Ibid).

Gender Socializationis a process of learning cultural gender roles according to one's sex. Boys are raised to conform to the male gender role, and girls are raised to conform to the female gender role (Ibid).

Gender Roles: are socially constructed roles and responsibilities assigned to men and women. Gender roles are learned through socialization process that specifically trains men and women in different behavioral categories and division of tasks that are considered appropriate for them according to the values and norms of the society (Ibid).

Male gender norms are the specific social expectations and roles assigned to men and boys in relation to women and girls. These often include ideas that men should take risks, endure pain, be tough, or should have multiple sexual partners – sometimes including paying for sex — to prove that they are “real men” (Ricardo and Barker, 2008).

Masculinities refer to the multiple ways that manhood is socially defined (Ibid).

Femininitiesrefer to the multiple ways that womanhood is socially defined (Ibid).

Gender Norms and their impact on the spread of HIV

Like in many other societies, in Ethiopia, gender norms are deeply rooted among the society. Notions of masculinity and femininity are socially constructed and reinforced by families, communities, mass media, peer groups and other institutions and govern the day to day lives of men and women. From birth, men and women are treated differently and are provided with different resources, information and opportunities (Karkara, 2007; Wingood and Diclemente, 2000 cited in WHO, 2003). Such kind of gender socialization often results in creating power differential between men and women, leaving both vulnerable to HIV/AIDS.

Masculinity and femininity are defined in communities globally by the shared perceptions they have about a 'typical man' and a 'typical woman'. In many cultures, including Ethiopia, a “real” man is traditionally defined asexhibiting strength, taking risks, being courageous and assertive, as well as who is able to give protection to his family both physically and financially (MHRC, 2004; WHO,2003). Norms about masculinity also encourage men to engage in risky behavior, such as having multiple partnerships, asserting sexual dominance, engaging in violent behaviors or consuming alcohol/drugs, often making men uniquely vulnerable to HIV (Campbell, 1995; WHO, 2003; MHRC, 2004; Karkara, 2006). At the same time, traditional male norms often stress independence and invulnerability, contributing to an unwillingness of men to seek HIV information or treatment (Men’s Health Forum, 2005; WHO, 2003). Since societies often ridicule boys and men who do not live up to these expectations, it leaves men with little option than to respond to these assigned male norms.

An ideal or a “real” woman on the other hand, is often expected to first meet the needs of her parents, and, after marriage, the needs of her husband (in terms of both household and childcare responsibilities, as well as sexually). Femininity also often signals passivity and delicateness,always agreeing to what a man says and seeking his protection (MHRC, 2004). While men are expected to openly assert their sexuality, women and girls are often expected to be less knowledgeable about sex and have less control over their sexuality (ECA, 2004; MHRC, 2004; WHO, 2003). Such kindcontrasting social expectations limit women’s sexual autonomy and encourage men’s sexual activity and control, resulting different health risks and vulnerabilities to HIV infection for women and men.

In addition, in almost every country worldwide, women have less access to and control of productive resources than men creating an unequal balance of power that favors men. Gender gaps between women and men in literacy, school enrollment, labor force participation, land ownership and access to credit testify to this imbalance in power (UNIFEM, 2000 cited in WHO, 2003). A study conducted in SNNPR and Oromia also shows that traditional gender norms have resulted in the denial of women to have access to property, services and information. Women exhibit lesser decision making power both at the household and the community levels (MHRC, 2004).

The imbalance in power created by a differential access to productive resources translates into an unequal balance of power in heterosexual interactions and intimate relationships, where men have greater control over their sexuality. In Ethiopia, for example, there is evidence that women often do not decide when and whom to marry or have sex and have limited ability to negotiate sexual terms within or outside marriage (MHRC, 2004).The power imbalances are also expressed in sexual relationships,giving men the ability to influence and/or determine women’s sexual and reproductive health choices, including utilization of health care services and use of modern contraceptives including condoms (Horizon’s Programme Report, 2001 cited in Chege, 2005; WHO, 2003).

These forms of how gender norms are expressed may be different in different contexts. Perceptions of masculinity may differ between societies and within societies and it also may change overtime (Karkara, 2007). However, due to lack of comprehensive data, some of the dominant male gender norms and practices identified asexacerbating factors for the vulnerability of men and women to HIV/AIDS are discussed below in more general terms.

2.1 Male norms and Violence against Women

Male norms and conceptions of masculinity play a major role in the perpetuation of gender-based violence. In 1993, the UN Declaration on the Elimination of all kinds of Violence against Women defined gender based violence as:

“…acts of physical, sexual and psychological violence in the family or community… that include: spousal battery, sexual abuse…rape, marital rape, female genital mutilation and other traditional practices harmful to women, non-spousal violence, sexual violence related to exploitation, sexual harassment and intimidation at work, in school and elsewhere, trafficking in women and forced prostitution” (UNFPA State of the World Population, 2005 cited in Population Council, 2009).

However, in all these different forms, gender based violence often involves men as perpetrators, and girls and women as victims of the violence which requires looking into how masculinity is constructed within the community settings. Young men often learn that it is considered masculine to be strong, dominant, sexually active and to exercise authority over women and children (Karkara, 2007). A study aimed at measuring males attitude and perception of family planning and family life in Amhara and Oromia regions, has also found that men’s dominance and women’s obedience to men are important components of family life (MHRC, 2002).

The socialization from early age of male’s dominance can promote physical, sexual and emotional violence, a problem that has become a daily reality for women and girls in the country. Boys, who observe fathers and other men in their surrounding being violent to other women, grow up believing that it is a normal male behavior, which may in turn encourage them to take violent measures, putting young men and women at particular risk (Karkara, 2007). Data compiled by WHO in 2005 indicates that nearly one third of Ethiopian women had been physically forced by a partner to have sex against their will within the 12 months prior to the study.

A report from Pathfinder in 2007, found thatnearly 8 percent of currently married women are abducted and forced into marriage. Young girls are married of to older men without their will and sometimes as a second or third wife in parts of the country where polygamy or wife inheritance is prevalent. The power imbalance however, contribute to men having the decision making power to determine where, when and how sex takes place within such kind of marital unions or outside marriage, leaving young girls with little or no option to determine their own sexuality.

According to Sida (2007)such kind of age disparate sex (cross-generational sex) is regarded as one form of coerced sex or sexual violence against young girls, which is a phenomenon in Ethiopia as demonstrated by a qualitative study recently undertaken in Nazereth and Addis Ababa. It was found that older men in these cities use their money and power to buy off young girls as a way of redressing what they have missed out in their youth. They consider having sexual relationship with younger women as an achievement. They want to feel young and show off that even in their old age they are man enough to win the love of young girls (MHRC, 2004).

The socio-economic disparities between these older men and the younger girls, make negotiating for safer sexual practices like using condom and mutual monogamy difficult, if not impossible. In many parts of the country, young women and girls are therefore repeatedly exposed to such kind of sexual violence that increases their risk of HIV infections (Ibid; ECA, 2004; Sida, 2007).

Gender-norms that are deeply entrenched within society has also supported the acceptance, by both men and women, of violence and coercion from spouses, boyfriends, sexual partners, and others.Wife beating for example is ingrained into cultures that women has also accepted it as normal and part of a women’s inferior status as her husband’s property. Findings from EDHS (2005), for example, suggest that violence against women is so accepted that an overwhelming majority (81%) of the women interviewed have reported that they believe there are justifiable reasons for ahusband to beat his wife.

Furthermore, a study conducted among young men (in and out of school) in Dessie Town suggests that the lack of employment opportunities and inability to fulfill their traditional gender roles as economic providers may lead young men to commit sexual violence to boost up their masculinity and self-esteem. Among these young people, manhood was often expressed by providing material goods for their partner and by the way a man dresses up. Men who cannot live up to this expectation, resort to other ways of expressing their masculinity, including the use of force or threat to use force in order tobegin a sexual relationship. Conversely, female informants of this study mentioned that many girls end up accepting a proposed relationship for fear of physical violence, abuse and beating (Getenet, 2006).

Importantly, acts of violence against women greatly increase vulnerability to HIV/AIDS, especially for women. Forced or coercive sex increases risk of exposure to the virus. Further, this form of violence indirectly increases vulnerability of women who live in abusive relationships or victims of rape as they are less likely to be able to negotiatethe conditions of sexual intercourse, especially condomuse (Pulerwitz et al, 2000 cited in Chege, 2005).In a study conducted among female factory workers in Ethiopia, rape victims were found to be nearly 4 times as likely to be HIV positive as compared to those who had not been raped (Mekonnen et al, 2004 cited in Population Council, 2009).

Although there are limited researches regarding gender based violence in the country; available ones have identified the role of male norms in the perpetuation of gender based violence and its link with the spread of the virus. The power dynamics that exists between women and men and the degree to which women are able to control the various aspects of their sexual lives plays a critical role in determining their vulnerability to HIV infection.

2.2 Male norms and sexuality

Growing up, boys and girls receive very different messages in relation to sexuality. Boys and men are frequently raised to believe that a “real” man needs to be strong and in control, particularly in their sexual relationships. Additionally, sexual experience is frequently associated with beginning of manhood. Effectively, many men construct their identities, understand and affirm their masculinity through their sexuality and their sexual experiences.This encourages men to be sexually active at an early age and to pursue sexual experience with different partners both inside and outside marriage (Karkara, 2007;Getenet, 2006; WHO, 2003). In Ethiopia, for example, a study conducted among communities in southern part of the country, about 60 percent of the respondents reported that it is acceptable and normal for men to be experienced in sex than women and sexual experience with multiple partners is often expected and regarded as “natural” to men (MHRC, 2004).