“A condom is compulsory”: A qualitative study of condom use and negotiation strategies among female sex workers in Nepal

ABSTRACT

The objective of this qualitative study was to understand Nepali female sex workers’ (FSWs) condom negotiation strategies. In 2016, we conducted 30 semi-structured, in-depth interviews with street- and brothel-based FSWs residing in Kathmandu, Nepal. Participants reported that their first entry into sex work typically occurred between the ages of 17–32, and the average duration of women’s involvement with sex work was 8 years. FSWs reported high knowledge and awareness of condoms, and many women had used various sexual and reproductive health services. FSWs used three types of negotiation strategies: withholding or refusing sex, providing risk information, and direct request. While some FSWs believed that these strategies were useful and successful, we found that, for some women, condom negotiation strategies were difficult to implement due to fear of abuse and threats of violence by clients. Condom negotiation was further complicated by poverty and substance abuse, and several narratives revealed the influence of gender and social norms on safe sexual practices. The findings highlight the need for improved sexual health interventions that incorporate a range of negotiation strategies and techniques (e.g., nonverbal communication and reward strategies) and aim to mitigate harm and violence against FSWs.     

Masculinity and male sexual behaviour in Mozambique

Like many countries in sub-Saharan Africa, Mozambique is facing a severe HIV epidemic. Evidence suggests that male sexual behaviour is one of the driving forces behind the epidemic. Yet, there is limited understanding of how notions of masculinity influence such behaviour in the context of HIV. Using data collected through focus group discussions and in-depth interviews with sexually active men and women, this paper investigates how notions of masculinity influence the risk of HIV infection among men. The study findings suggest that traditional norms of masculinity, the man as the main provider and figure of authority, continue to exert a strong influence on male attitudes and behaviour. Alternative approaches are urgently needed in HIV programming that take into consideration notions of masculinity in order to reduce risky sexual behaviour.     

Women on men’s sexual health and sexually transmitted infection testing: a gender relations analysis

Sexual health and sexually transmitted infection (STI) testing is typically portrayed as a women’s issue amid men’s estrangement from healthcare services. While the underreporting of men’s STIs has been linked to masculinities, little is known about how women interpret and respond to heterosexual men’s sexual health practices. The findings drawn from this qualitative study of 34 young women reveal how femininities can be complicit in sustaining, as well as being critical of and disrupting masculine discourses that affirm sexual pleasure and resistance to health help‐seeking as men’s patriarchal privileges. Our analysis revealed three patterns: looking after the man’s libido refers to women’s emphasised femininity whereby the man’s preference for unprotected sex and reticence to be tested for STIs was accommodated. Negotiating the stronger sex refers to ambivalent femininities, in which participants strategically resist, cooperate and comply with men’s sexual health practices. Rejecting the patriarchal double standard that celebrates men as ‘studs’ and subordinates women as ‘sluts’ for embodying similar sexual practices reflects protest femininities. Overall, the findings reveal that conventional heterosexual gender relations, in which hegemonic masculinity is accommodated by women who align to emphasised femininity, continues to direct many participants’ expectations around men’s sexual health and STI testing.     

Traditional gender roles,forced sex and HIV in Zimbabwean marriages

Little is known on how forced sex contributes to the sexual transmission of HIV in marriage. This paper describes traditional gender norms surrounding forced sex in Zimbabwean marriage. Data were collected from 4 focus group discussions and 36 in-depth interviews with married women and men in Harare. Results indicate that hegemonic masculinity characterised by a perceived entitlement to sex, male dominance and being a provider contributed to forced sex in marriage. A femininity characterised by a tolerance of marital rape, the desire to please the husband and submission contributed to women experiencing forced sex. An alternative femininity characterised by sexual pleasure-seeking contributed to women forcing their spouses to have sex. Future HIV interventions must go beyond narrowly advocating for safer sex within marriage and instead address practices that increase risk as well as promote positive marital relationship needs such as mutual respect, love and friendship.     

Traditional gender roles, forced sex and HIV in Zimbabwean marriages

Little is known on how forced sex contributes to the sexual transmission of HIV in marriage. This paper describes traditional gender norms surrounding forced sex in Zimbabwean marriage. Data were collected from 4 focus group discussions and 36 in-depth interviews with married women and men in Harare. Results indicate that hegemonic masculinity characterised by a perceived entitlement to sex, male dominance and being a provider contributed to forced sex in marriage. A femininity characterised by a tolerance of marital rape, the desire to please the husband and submission contributed to women experiencing forced sex. An alternative femininity characterised by sexual pleasure-seeking contributed to women forcing their spouses to have sex. Future HIV interventions must go beyond narrowly advocating for safer sex within marriage and instead address practices that increase risk as well as promote positive marital relationship needs such as mutual respect, love and friendship.     

The structural influence of family and parenting on young people's sexual and reproductive health in rural northern Tanzania

This paper explores the structural role of the family and parenting in young people's sexual and reproductive health. The study involved eight weeks of participant observation, 26 in-depth interviews, and 11 group discussions with young people aged 14–24 years, and 20 in-depth interviews and 6 group discussions with parents/carers of children in this age group. At an individual level, parenting and family structure were found to affect young people's sexual behaviour by influencing children's self-confidence and interactional competence, limiting discussion of sexual health and shaping economic provision for children, which in turn affected parental authority and daughters' engagement in risky sexual behaviour. Sexual norms are reproduced both through parents' explicit prohibitions and their own behaviours. Girls are socialised to accept men's superiority, which shapes their negotiation of sexual relationships. Interventions to improve young people's sexual and reproductive health should recognise the structural effects of parenting, both in terms of direct influences on children and the dynamics by which structural barriers such as gendered power relations and cultural norms around sexuality are transmitted across generations.     

Amigos and amistades: the role of men's social network ties in shaping HIV vulnerability in the Dominican Republic

While men's social networks have been identified as a source of influence on sexual behaviour, less is known about the different types of friendship ties within men's networks. We analysed data from qualitative in-depth interviews with 36 men in Santo Domingo, Dominican Republic who are current or former sexual partners of female sex workers to understand how: (1) men describe trust and communication with different types of friendship ties, (2) characteristics of trust and communication reflect norms of masculinity, and (3) these friendship ties influence HIV-related behaviours. We identified a distinction between amistades, social drinking buddies who are not trusted, and amigos, trusted friends. The majority of men lacked any amigos and some had neither amigos nor amistades. In general, men reflected traditional norms of masculinity and said they did not feel they could discuss their relationships or emotional topics with other men. Trust and communication dynamics, and how norms of masculinity shape those dynamics, should be understood and addressed in the design of HIV prevention efforts with men's social networks as they have implications for the potential effectiveness of such efforts.     

Being and feeling like a woman: respectability,responsibility, desirability and safe sex among women of Afro‐Surinamese and Dutch Antillean descent in the Netherlands

The objective of this study was to describe and understand gender roles and the relational context of sexual decision‐making and safe sex negotiation among Afro‐Surinamese and Dutch Antillean women in the Netherlands. Twenty‐eight individual in‐depth interviews and eight focus group discussions were conducted. In negotiating safe sex with a partner, women reported encountering ambiguity between being respectable and being responsible. Their independence, autonomy, authority and pride inherent to the matrifocal household give them ample opportunity to negotiate safe sex and power to stand firm in executing their decisions. The need to be respectable burdens negotiation practices, because as respectable, virtuous women there would not be the need to use condoms. Respectable women will only participate in serious monogamous relationships, which are inherently safe. Women's desire to feel like a woman, ‘to tame the macho‐man’ and constrain him into a steady relationship, limits negotiation space because of emotional dependency. Respectability seems to enforce not questioning men's sexual infidelity. In developing STI/HIV prevention programmes this ambiguity due to cultural values related to gender roles should be considered. Raising awareness of power differences and conflicting roles and values may support women in safe‐sex decision‐making.     

Masculinity and male sexual behaviour in Mozambique

Like many countries in sub-Saharan Africa, Mozambique is facing a severe HIV epidemic. Evidence suggests that male sexual behaviour is one of the driving forces behind the epidemic. Yet, there is limited understanding of how notions of masculinity influence such behaviour in the context of HIV. Using data collected through focus group discussions and in-depth interviews with sexually active men and women, this paper investigates how notions of masculinity influence the risk of HIV infection among men. The study findings suggest that traditional norms of masculinity, the man as the main provider and figure of authority, continue to exert a strong influence on male attitudes and behaviour. Alternative approaches are urgently needed in HIV programming that take into consideration notions of masculinity in order to reduce risky sexual behaviour.     

Adjusting hormones and constructing desires: new materialisations of female sexuality in Brazil

This paper presents the findings from a study conducted in Brazil among doctors specialised in the treatment of sexual problems. Its focus is on medical treatments and approaches related to female sexuality. According to the accounts provided by professionals, the most common ‘problem’ they encountered among women was lack of sexual desire in the period around menopause. In line with current principles of sexual medicine, they concurred that this issue resulted from declining hormone production. This paper discusses how pharmaceutical treatments have facilitated the materialisation of female desire in terms of the presence or absence of testosterone, paradoxically the hormone most commonly associated with masculinity.     

Sexual orientation and eating psychopathology: the role of masculinity and femininity

OBJECTIVE: Previous research suggests that eating disorders are related to homosexuality in men, although links with female sexual orientation are less clear. Appearance factors have generally been implicated in this relationship. However, previous studies have failed to consider the role of femininity, even though evidence suggests that this is a more critical factor than sexual preference. The aim of this study was to consider the relationship between gender-role orientation and eating psychopathology in nonclinical men and women of different sexual orientations. METHOD: One hundred university students (40 homosexual; 60 heterosexual) completed the Bem Sex Role Inventory and the Eating Attitudes Test. RESULTS: For the group as a whole, there were links between femininity and high levels of eating psychopathology, whereas masculinity was associated with relatively healthy eating-related attitudes and behaviors. When considering the role of sexual orientation, these links were specific to homosexual men and women. CONCLUSIONS: In relation to homosexual men and women, the results support a model where femininity might be seen as a specific risk factor for eating disorders, whereas masculinity is likely to be a protective factor. Methodological and conceptual implications are discussed.     

The influence of social constructs of hegemonic masculinity and sexual behaviour on acceptability of vaginal microbicides in Zambia

Vaginal microbicides are heralded as a woman’s HIV prevention method. This study, conducted in a microbicide clinical trial setting in Zambia, explored how the social construction of masculinity and sexual behaviour influenced the acceptability of vaginal microbicides. The data were generated from 18 In-depth Interviews and 8 Focus Group Discussions. The data were analysed thematically. The study found that hegemonic masculinity influenced the use of vaginal microbicides positively and negatively, in multiple ways including: decision to initiate gel use, autonomous use of the gel, and consistent use of the gel. Men were seen as heads of households and decision-makers who approved their partners’ intentions to initiate gel use. Autonomous gel use by women was not supported because it challenged men’s dominant position in sexual matters and at a family level. The socially accepted notion that men engaged in multiple sexual relationships also influenced women’s decision to use the gel. Sustained gel use depended on the perceived effect of the gel on men’s sexual desires, sexual performance, fertility, and sexual behaviour. This study suggests that acceptability of microbicides partially lies within the realm of men, with use constrained and dictated by cultural constructs and practice of masculinity and gender.     

Constructions of masculinity and their influence on men's well-being: a theory of gender and health

Men in the United States suffer more severe chronic conditions, have higher death rates for all 15 leading causes of death, and die nearly 7 yr younger than women. Health-related beliefs and behaviours are important contributors to these differences. Men in the United States are more likely than women to adopt beliefs and behaviours that increase their risks, and are less likely to engage in behaviours that are linked with health and longevity. In an attempt to explain these differences, this paper proposes a relational theory of men's health from a social constructionist and feminist perspective. It suggests that health-related beliefs and behaviours, like other social practices that women and men engage in, are a means for demonstrating femininities and masculinities. In examining constructions of masculinity and health within a relational context, this theory proposes that health behaviours are used in daily interactions in the social structuring of gender and power. It further proposes that the social practices that undermine men's health are often signifiers of masculinity and instruments that men use in the negotiation of social power and status. This paper explores how factors such as ethnicity, economic status, educational level, sexual orientation and social context influence the kind of masculinity that men construct and contribute to differential health risks among men in the United States. It also examines how masculinity and health are constructed in relation to femininities and to institutional structures, such as the health care system. Finally, it explores how social and institutional structures help to sustain and reproduce men's health risks and the social construction of men as the stronger sex.     

Conflicting contraceptive norms for men: equal responsibility versus women’s bodily autonomy

Most research investigating how men and women in heterosexual relationships negotiate contraceptive use focuses on the women’s point of view. Using a sample of 44 interviews with men attending a western US university, this study examines norms governing men’s participation in contraceptive use and pregnancy prevention and their responses to those norms. The paper demonstrates how competing norms around sexual health decision-making and women’s bodily autonomy contribute to unintended outcomes that undermine young people’s quest for egalitarian sexual relationships. While men largely agree that responsibility for sexual health decision-making should be shared with women, they also believe that women should have power over their own bodies and sexual health. However, the coexistence of these two competing norms – which call for both equal responsibility in decision-making and women’s bodily autonomy – results in a disconnect between men saying that sexual health decision-making should be equal, but not always participating equally. Thus, men largely give contraceptive decision-making power over to women, putting the burden of pregnancy prevention onto women and letting men off the hook. It is concluded that men’s negotiation of these competing norms reinforces unequal power and inequality in sexual relationships.     

Gender relations, prostate cancer and diet: re-inscribing hetero-normative food practices

Although diet might be a valuable adjunct to prostate cancer care, men typically have poorer diets than women and are less likely to change the way they eat after a cancer diagnosis. Gender theory suggests that dominant ideals of masculinity shape men's health and food practices; however, the role of female partners in men's diets is poorly understood. Through qualitative analysis of in-depth interviews, this article explores accounts of 14 Canadian couples' food practices guided by a gender relations framework to expose how tacit performances of masculinity and femininity interact to shape the diets of men with prostate cancer. Findings show that many men became more interested and involved in their diets after a prostate cancer diagnosis, practices that might be theorized as a counter hegemonic project or 'feminization', adding to other prostate cancer induced emasculations (i.e., treatment induced incontinence and impotence). At the same time, however, couples mutually limited men's engagement with diet while concurrently reinforcing women's traditional femininities in nurturing the men in their lives through food provision. Also embedded here were women's attempts to mitigate subordinate productions of masculinity by catering to their partner's tastes as well as monitoring their diets. Most couples mutually maintained traditional gender food 'roles' by positioning women as proficient leaders in domestic food provision and men as unskilled 'try-hard' and sometimes uninterested assistants. Findings also revealed complex gender power dynamics that predominated as complicit in sustaining hegemonic masculinity through women's deference to men's preferences and careful negotiation of instrumental support for men's diet changes. Overall men and women jointly worked to re-inscribe hetero-normative family food practices that shaped men's diets and nutritional health.     

Delaying sexual debut amongst out-of-school youth in rural southwest Uganda

This paper focuses on ‘sexual debut’ among out-of-school youth in Masaka District, Uganda, factors influencing its timing and assistance young people feel they need to delay sexual initiation. Data were drawn from a sexual health needs assessment using applied anthropological techniques with young people aged 13–19 years. Parents, guardians and community leaders were also consulted. All participants felt that young people begin their sexual lives too early. Young men feel under pressure from friends and older men to prove their masculinity. Most delay further activity after debut and want assistance to resist the pressure. Young women's debut after physical maturation prompts ‘pestering’ for sex from boys and men who offer gifts. After debut, young women remain sexually active but believe younger women need assistance to resist pressure. Programmes are needed to help young people achieve these goals. Structurally, the community needs to develop means of preventing men from pestering young women for sex and of redeveloping both the social role and pathway to marriage for young women who are marrying later than is traditional.     

Words can hurt: The effects of physical and psychological partner violence on condom negotiation and condom use among young women

ABSTRACT

Physical and psychological intimate partner violence (IPV) are prevalent on college campuses and may affect young women’s condom use behavior. This study explored condom negotiation as a mediator of the relation of physical and psychological IPV to condom use among college women. A total of 235 heterosexual college women were recruited during September 2012–May 2013. Participants completed online questionnaires assessing lifetime history of IPV, frequency of condom negotiation, and use of condoms during the last 30 days. Specific forms of psychological IPV were related to less condom use. This association was mediated by condom negotiation, such that those who had experienced psychological IPV were less likely to negotiate condom use, and as a result, less likely to report using condoms in the past 30 days. Campus-based sexual health efforts should consider the relation of psychological IPV to condom negotiation and condom use and offer skills to promote condom negotiation among college women to increase condom use and reduce their risk of sexually transmitted infections.