In developing programs that integrate family planning with services to prevent or treat
sexually transmitted diseases (STDs), healthcare providers should recognize factors that
can influence women's access to, or use of, reproductive health services:
Biology -- STD transmission, including transmission of the AIDS virus, may be
easier from men to women than from women to men because a large area of vaginal and
cervical mucosa is exposed to male sexual fluids during intercourse.1
STDs, which can be a risk factor in acquiring HIV, are more often asymptomatic in women
than in men, so many women do not realize they have an STD. Family planning clinics can
help women evaluate their STD risks, recognize symptoms and understand how to protect
themselves.
Economics -- For many women, sexual relationships are often linked directly or
indirectly to economic security. For example, a woman may want to become pregnant because
children provide marital stability or status within the community.2
Consequently, she may avoid using condoms despite a need for disease prevention. For some
women, sex is a means of economic survival. A study in Haiti, conducted by FHI's AIDS
Control and Prevention (AIDSCAP) project, found many women feared that their partners
would withhold money for rent, child care, food and other items if they refused sexual
relations.3 In the Dominican Republic, researchers found that
among women living in bateyes, plantations where sugar cane is harvested, one-fifth
had traded sex for money.4
Cultural norms -- In many cultures, men are viewed as authority figures, and
women are discouraged from questioning their partners' actions. "If you cannot talk
to your partner about the children's school fees, or where you are going to live -- if you
cannot ask the man where he is going when he leaves the house -- you definitely cannot
talk about condoms," says Dr. Maxine Ankrah of the AIDSCAP Women's Initiative.
In some societies, women are expected to have one partner, while it is acceptable for
men to have several wives or to have partners outside of marriage. One young married woman
in Cambodia explained, "In Khmer society, it is nothing for men to have other
partners or a second wife because people compare the men to gold and the women to
cotton."5 Social taboos also discourage women from
talking or learning about sex, believing that ignorance is a sign of purity.
Risk perceptions -- Because AIDS prevention programs have often been targeted
toward high-risk groups, including commercial sex workers, many women do not perceive
themselves at risk of HIV infection. Research conducted in Brazil, supported by FHI, found
that "although women know how HIV can be transmitted, they do not perceive themselves
to be at risk because they are married or in a consensual union. Women believe if they
stay with one partner, they will be protected."6
Male latex condoms, the only contraceptive recommended for protection against both
viral and bacterial STDs, are often viewed as a method that is used between casual sex
partners but not husbands and wives. In Thailand, approximately 70 percent of couples of
reproductive age use some form of contraception, but only 2 percent of married couples use
condoms.7 If a woman suggests condom use, her partner may
suspect she is unfaithful -- or that she thinks he is unfaithful. Researchers in Thailand
found that among the more than 700 men and woman interviewed, 60 percent said that condoms
should not be used with spouses or regular partners because it might create tension or
mistrust.8
-- Barbara Barnett
References
- Guidelines for Implementing STD/HIV/AIDS Prevention
and Care in Reproductive Health Services. Draft. Arlington: Family Health
International AIDSCAP Project, 1996.
- D'Cruz-Grote D. Prevention of HIV infection in
developing countries. Lancet 1996; 348: 1071-74.
- Ulin PR, Cayemittes M, Metellus E. Haitian Women's
Role in Sexual Decision-making: The Gap Between AIDS Knowledge and Behavior Change. Durham:
Family Health International, 1995.
- Study underscores need to empower women. The Daily
Progress. July 9, 1996.
- Phan H, Patterson L. Men are Gold, Women are Cloth. A
Report on the Potential for HIV/AIDS Spread in Cambodia and Implications or HIV/AIDS
Infection. Phnom Penh: CARE International, 1994.
- Badiani R, de Oliveira MR, Pinto P, et al. Empowering
Women to Negotiate Safe Sex: A Model from Brazil. XXIIth National Council for
International Health, Washington, DC, June 1995.
- Knodel J. Chamratrithirong A, Debavalya N. Thailand's
Reproductive Revolution: Rapid Fertility Decline in a Third World Setting. Madison:
University of Wisconsin Press, 1987. National Statistical Office. Report on the Survey
of Population Change, 1991. Bangkok: Np, Nd.
- Sittitrai W. Thai Sexual Behavior and the Risk of HIV
Infection: A Report of the 1990 Survey of Partner Relations and Risk of HIV Infection in
Thailand. Bangkok: Thai Red Cross Society and Chulalongkorn University, 1992.
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