Attitudes to Sexuality and Family Planning

Bauni EK,1 Garimoi CO,2 Maharaj P,3 Mushingeh ACS,4 Neema S,2
Ngirwamungu E,5 and Riwa P5

The African focus group discussions (FGDs) were particularly revealing with regard to the attitudes of individuals and communities to sexual and reproductive matters. It was generally agreed, for instance, that limiting sexual activity to one regular partner or consistently using condoms if one has more than one partner are the best ways to avoid infection with HIV/STDs. Yet, it was equally agreed that large numbers of people do not do this and thus frequently put themselves, and others, at risk.

Misinformation and barriers to communication between spouses

In Kenya, the focus group discussions pointed to cultural beliefs, ignorance and men's lack of cooperation as the main barriers to communication between partners on contraception and STD prevention. "Religious teaching" was also mentioned as one of the disincentives to condom use.

In the Uganda study, condoms were used chiefly with new partners and in extramarital relationships but were abandoned as a relationship became regular.

In South Africa it was felt that many people believe "it can't happen to them". The South Africa research found beliefs not only that AIDS was caused by unsafe sex but also that vulnerability to the disease was increased by sexual dishonesty, infidelity, rape and poverty. It was mentioned that sexual abstinence, blood-testing and a healthy lifestyle could protect one from the disease. At the same time, the participants agreed that there was a lack of information about AIDS.

The FGDs in Tanzania suggested that family planning is understood as a means for spacing or limiting births for the welfare of the mother and child. However, according to the focus groups, men consider it a responsibility of women, while women consider it a responsibility of both partners.

The Zambian research indicated that communication between spouses on subjects such as HIV and other STDs was absent or extremely limited. Apart from the usual causes of HIV infection, some participants mentioned that having sex with a woman who has aborted or whose husband has died may cause the disease, and some said that eating imported foodstuffs or using condoms could cause it.

Only a minority uses condoms

The FGD participants in Kenya felt that family planning was not widely practised in their area and that, although knowledge about condoms was widespread, their acceptability was very low. In South Africa, the pill, injectables and natural methods of family planning were identified as possible methods of preventing pregnancy. Perceived barriers to condom use included breakage, reduction in sexual pleasure, interruption of sexual activity and lack of knowledge. The biggest problem mentioned by women with regard to condoms was that they require the partner's cooperation.

The Tanzanian research indicated that condoms were readily available in local shops and were known to be effective in preventing pregnancy. Non-use of condoms was associated by the participants with breakage, loss of sexual pleasure, bruising, their supposed contamination with HIV, and the possibility of condoms remaining inside the woman's womb. Nevertheless, the FGD participants agreed that condoms were acceptable for preventing STDs, including HIV/AIDS.

In Uganda, condoms were known by both married and unmarried persons and were sometimes distributed by health workers, but were rarely used in marriage relationships. Problems identified with condoms related to their safety and reliability, lack of sexual enjoyment, fear of side-effects, and the fear that condom lubricants might contain HIV.

In Zambia, condoms were the second best known method of fertility regulation after the pill, but they were most commonly mentioned with regard to premarital or extramarital sex. Objections to the use of condoms included breakage, lack of sexual satisfaction, stomach pains and genital rash.

Condoms seen as unsuited to married couples

There was also a strong belief in the Kenyan focus groups that condoms should be used only in sexual contacts outside marriage. The idea of using condoms with a marriage partner was rejected especially by the men since "condom use in marriage portends unfaithfulness which leads to mistrust". While some of the women's groups accepted the idea of using condoms together with another contraceptive method where there is a double risk of unwanted pregnancy and contracting an STD, the men seemed to be the major barrier to such double-method use. Condoms were mentioned as a contraceptive method by the South African groups but they were mostly associated with the prevention of STDs.

In a discussion of family planning the FGD participants in Tanzania identified various groups of women as users (of family planning). However, men were not mentioned in this regard since condoms were considered primarily for the prevention of STDs. Condoms were reported to be used for extramarital affairs but were thought to be unnecessary for married couples because they "trust" each other.

In the Uganda study, condoms were chiefly used with new partners and in extramarital relationships but were abandoned as a relationship became regular. Nevertheless, male groups felt it would be acceptable to use them within a marriage. The women's groups felt that use within marriage would be impossible, however, and in any case they felt that pills and injectables were more acceptable methods of contraception.

In Zambia, condoms were known as contraceptives, along with pills, injectables and traditional methods of family planning, but condoms were particularly associated with sex workers, teenage sex, extramarital affairs, and use during menstruation.

Women too dependent on men to protect themselves

While some of the women's groups accepted the idea of using condoms together with another contraceptive method where there is a double risk of unwanted pregnancy and contracting an STD, the men seemed to be the major barrier to such double-method use.

In a discussion about the resumption of sex after pregnancy, most of the Kenyan groups felt that three months would be the ideal period for a couple to abstain from sex after a woman has given birth. Nevertheless, the researchers concluded, many men would have affairs with other women during this period. In situations where there is a fear of contracting an STD, including HIV, from a spouse, women seemed to be very vulnerable in view of men's leading role in the family and community. Some women said they could not do anything to protect themselves from infection, they could not ask their husband to use a condom, could not refuse to have sex, and could not talk about the problem with their husband. Only a few women in the focus groups said they could refuse to have sex with their husband.

In South Africa, both men and women agreed that it would be difficult to insist on condom use and refuse sex within marriage. All groups said that a woman who feared infection by her partner should try to convince him to use a condom, but all also felt that this would not be easy as women have to submit to male demands or face rejection or violence.

In the Tanzanian groups, men and women had differing opinions on whether a woman could protect herself from being infected with an STD by her partner. Men felt that the woman could do nothing to protect herself but women mentioned condom use, laboratory tests and divorce if necessary, though it was clear that they accepted that violence was a real possibility in such a situation. FGD participants reported that some couples do discuss issues such as childbearing and fertility regulation, particularly in view of the cost of bringing up a large family. It was also said that even where discussion does not take place some married women use contraception secretly.

Most of the people in the Zambian groups said they would not willingly go for an HIV/AIDS test as they would be afraid of the psychological consequences.

Refusing sex or asking a man to use a condom was likely to lead to violence, rejection and separation, the Ugandan groups said. Methods identified for changing a man's behaviour included asking a traditional healer to bewitch him, pampering him, being attractive for him, and leaving home so that he begs you to come back. Discussion of birth spacing and contraception was felt to be more likely if couples were happy together, if the marriage was monogamous, and among young and more educated couples. Where couples did not discuss STDs, this was felt to be due to fear of conflict and to the traditional attitude that men are the decision-makers.

Similarly, in Zambia, communication between spouses on reproductive issues was said to be limited at best, with most men disapproving of contraception. This, the participants said, led to disagreement among couples, which in turn led to women being beaten, divorced or rejected.

Sources

1. Bauni EK. Family planning and sexual behaviour in the era of HIV/AIDS/STDs: a multicountry study—Kenya. Nairobi, Population Council, 1998.

2. Neema S, Garimoi CO. Family planning and sexual behaviour in the era of HIV/AIDS/STDs: a multicountry study—Uganda. Kampala, Makerere Institute of Social Research, 1998.

3. Maharaj P. Family planning and sexual behaviour in the era of HIV/AIDS/STDs: a multicountry study—South Africa. University of Natal, 1998.

4. Mushingeh ACS. Family planning and sexual behaviour in the era of HIV/AIDS/STDs: a multicountry study—Zambia. University of Zambia, 1998.

5. Riwa P, Ngirwamungu E. Perception of the risk of STD/HIV/AIDS and unwanted pregnancy. National Family Planning Programme, Ministry of Health, 1998.

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