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*The views expressed in this paper, which has been reproduced as received, are those of the author and do not necessarily represent those of the 51³Ô¹Ï.

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The focus of my talk, as the title suggests, is on gender-sensitive ways to empower women in order to protect them in the HIV/AIDS pandemic. The talk is limited to issues related to the heterosexual transmission of HIV because that has been the focus of my work over the last decade. I recognize that heterosexual transmission is only one aspect of the epidemic, but it is by no means irrelevant since the most recent statistics show that heterosexual transmission of HIV remains by far the most common mode of transmission globally.

We have known for at least a decade that gender and sexuality are significant factors in the sexual transmission of HIV, and we now know that they also influence treatment, care, and support. Both terms, nevertheless, continue to remain misunderstood and inappropriately used.

Gender is not a synonym for sex. It refers to the widely shared expectations and norms within a society about appropriate male and female behavior, characteristics, and roles. It is a social and cultural construct that differentiates women from men and defines the ways in which women and men interact with each other.

Gender is a culture-specific construct – there are significant differences in what women and men can or cannot do in one culture as compared to another. But what is fairly consistent across cultures is that there is always a distinct difference between women's and men's roles, access to productive resources, and decision-making authority. Typically, men are seen as being responsible for the productive activities outside the home while women are expected to be responsible for reproductive and productive activities within the home. And we know from over twenty years of research on women's roles in development that women have less access over and control of productive resources than men -- resources such as income, land, credit, and education. While the extent of this difference varies considerably from one culture to the next, it almost always persists (Sivard et al.1995; Buvinic 1995).

Sexuality is distinct from gender yet intimately linked to it. It is the social construction of a biological drive. An individual’s sexuality is defined by whom one has sex with, in what ways, why, under what circumstances, and with what outcomes. It is more than sexual behavior and is a multidimensional and dynamic concept. Explicit and implicit rules imposed by society, as defined by one’s gender, age, economic status, ethnicity and other factors, influence an individual’s sexuality (Zeidenstein and Moore 1996; Dixon Mueller 1993).

At the Center at which I work, we talk about the components of sexuality as the Ps of sexuality – practices, partners, pleasure/pressure/pain, and procreation. The first two refer to aspects of behavior -- how one has sex and with whom; while the others refer to the underlying motives. But we have learned through data gathered over many years that there is an additional P of sexuality that is the most important -- power. The power underlying any sexual interaction, heterosexual or homosexual, determines how all the other Ps of sexuality are expressed and experienced. Power determines whose pleasure is given priority and when, how, and with whom sex takes place. Each component of sexuality is closely related to the other but the balance of power in a sexual interaction determines its outcome (Weiss and Rao Gupta 1998).

Power is fundamental to both sexuality and gender. The unequal power balance in gender relations that favors men, translates into an unequal power balance in heterosexual interactions, in which male pleasure supercedes female pleasure and men have greater control than women over when, where, and how sex takes place. An understanding of individual sexual behavior, male or female, thus, necessitates an understanding of gender and sexuality as constructed by a complex interplay of social, cultural, and economic forces that determine the distribution of power.

Research supported by ICRW and conducted by researchers worldwide has identified the different ways in which the imbalance in power between women and men in gender relations curtails women's sexual autonomy thereby increasing their risk and vulnerability in the HIV/AIDS pandemic (Weiss and Rao Gupta 1998; de Bruyn et al. 1995; Heise and Elias 1995).

Women’s Vulnerability

First, in many societies there is a culture of silence that surrounds sex that dictates that "good" women are expected to be ignorant about sex and passive in sexual interactions. This makes it difficult for women to be informed about risk reduction or, even when informed, makes it difficult for them to be proactive in negotiating safer sex (Carovano 1992).

Second, the traditional norm of virginity for unmarried girls that exists in many societies, paradoxically, increases young women’s risk of infection because it restricts their ability to ask for information about sex out of fear that they will be thought to be sexually active. Virginity also puts young girls at risk of rape and sexual coercion in high prevalence countries because of the erroneous belief that sex with a virgin can cleanse a man of infection and because of the erotic imagery that surrounds the innocence and passivity associated with virginity. In addition, in cultures where virginity is highly valued, research has shown that some young women practice alternative sexual behaviors, such as anal sex, in order to preserve their virginity, although these behaviors may place them at increased risk of HIV (Weiss, Whelan, and Rao Gupta 2000).

Third, because of the strong norms of virginity and the culture of silence that surrounds sex, accessing treatment services for sexually transmitted diseases can be highly stigmatizing for adolescent and adult women (Weiss, Whelan, and Rao Gupta 2000; de Bruyn et al. 1995).

Fourth, in many cultures because motherhood, like virginity, is considered to be a feminine ideal, using barrier methods or non-penetrative sex as safer sex options presents a significant dilemma for women (Heise and Elias 1995; UNAIDS 1999).

Fifth, women’s economic dependency increases their vulnerability to HIV. Research has shown that the economic vulnerability of women makes it more likely that they will exchange sex for money or favors, less likely that they will succeed in negotiating protection, and less likely that they will leave a relationship that they perceive to be risky (Heise and Elias 1995; Mane, Rao Gupta, and Weiss 1994; Weiss and Rao Gupta 1998).

And finally, the most disturbing form of male power, violence against women, contributes both directly and indirectly to women's vulnerability to HIV. In population-based studies conducted worldwide, anywhere from 10 to over 50 percent of women report physical assault by an intimate partner. And one-third to one-half of physically abused women also report sexual coercion (Heise, Ellsberg, and Gottemoeller 1999).

A review of literature on the relationship between violence, risky behavior, and reproductive health, conducted by Heise and colleagues (1999) shows that individuals who have been sexually abused are more likely to engage in unprotected sex, have multiple partners, and trade sex for money or drugs. This relationship is also apparent in the findings from a study conducted in India. In this study men who had experienced extramarital sex were 6.2 times more likely to report wife abuse than those who had not. And men who reported STD symptoms were 2.4 times more likely to abuse their wives than those who did not (Martin et al. 1999). And from other research we also know that physical violence, the threat of violence, and the fear of abandonment act as significant barriers for women who have to negotiate the use of a condom, discuss fidelity with their partners, or leave relationships that they perceive to be risky (Mane, Rao Gupta, and Weiss 1994; Weiss and Rao Gupta 1998).

Additionally, data from a study conducted in Tanzania by Maman, Mbwambo, and colleagues (2000) suggest that for some women the experience of violence could be a strong predictor of HIV. In that study, of the women who sought services at a voluntary HIV counseling and testing center in Dar-es- Salaam, those who were HIV positive were 2.6 times more likely to have experienced violence in an intimate relationship than those who were negative.

Power Imbalance and HIV/AIDS

In addition to increasing the vulnerability of women and men to HIV, the power imbalance that defines gender relations and sexual interactions also affects women’s access to and use of services and treatments. For example, the Tanzanian study conducted by Maman, Mbwambo and colleagues (1999) found that there were gender differences in the decision-making that led to the use of HIV voluntary counseling and testing services. While men made the decision to seek voluntary counseling and testing independent of others, women felt compelled to discuss testing with their partners before accessing the service, thereby creating a potential barrier to accessing VCT services.

Women's social and economic vulnerability and gender inequality also lie at the root of their painful experiences in coping with the stigma and discrimination associated with HIV infection. HIV positive women bear a double burden: they are infected and they are women. In many societies being socially ostracized, marginalized and even killed are very real potential consequences of exposing one's HIV status. Yet, HIV testing is a critical ingredient for receiving treatment or for accessing drugs to prevent the transmission of HIV from a woman to her child.

In a recent study conducted by researchers in Botswana and Zambia in collaboration with researchers from ICRW, men and women expressed concern for women who test positive because they felt that men would be likely to abandon a HIV positive partner. On the other hand, it was expected that women would initially get angry with a HIV positive partner, but ultimately accept him (Nyblade and Field 2000).

Overcoming Inequality

How is one to overcome these seemingly insurmountable barriers of gender and sexual inequality? How can we change the cultural norms that create these damaging, even fatal, gender disparities and roles?

It is easier now to explain the why and what with regard to gender, sexuality, and HIV/AIDS, but there is less known about the how – how to address these issues in a way that has an impact on the epidemic. It must be said, however, that this relatively little information on the how is not due to a lack of innovation and trying. Although there are still no clear-cut answers and there is very little data to establish the impact of the efforts that have been tried, it is possible to look back and identify clear-cut categories of approaches--approaches that fall at different points on a continuum from damaging to empowering.

To effectively address the intersection between HIV/AIDS and gender and sexuality requires that interventions should, at the very least, not reinforce damaging gender and sexual stereotypes. Many of our past and, unfortunately, some of our current efforts, have fostered a predatory, violent, irresponsible image of male sexuality and portrayed women as powerless victims or as repositories of infection. This poster, in which a sex worker is portrayed as a skeleton, bringing the risk of death to potential clients, is an example of the latter which, from experience we can predict, probably succeeded in doing little other than stigmatizing sex workers, thereby increasing their vulnerability to infection and violence. There are many other examples of such damaging educational materials. A particularly common type is one that exploits a macho image of men to sell condoms. No amount of data on the increase in condom sales is going to convince me that such images are not damaging in the long run. Any gains achieved by such efforts in the short-term are unlikely to be sustainable because they erode the very foundation on which AIDS prevention is based -- responsible, respectful, consensual, and mutually satisfying sex.

Gender-sensitive Approaches

In contrast, gender-sensitive programming that recognizes and responds to the differential needs and constraints of individuals based on their gender and sexuality is a definite step forward on the continuum of progress. The defining characteristic of such interventions is that they meet the different needs of women and men. Providing women with a female condom or a microbicide is an example of such programming. It recognizes that the male condom is a male-controlled technology and it takes account of the imbalance in power in sexual interactions that makes it difficult for women to negotiate condom use by providing women with an alternate, woman-initiated technology. Efforts to integrate STD treatment services with family planning services to help women access such services without fear of social censure is another example of such an approach. We know that such pragmatic approaches to programming are useful and necessary because they respond to a felt need and often significantly improve women's access to protection, treatment, or care. But by themselves they do little to change the larger contextual issues that lie at the root of women's vulnerability to HIV. In other words, they are necessary, even essential, but not sufficient to fundamentally alter the balance of power in gender relations.

Transformative Approaches

Next on the continuum are approaches that seek to transform gender roles and create more gender-equitable relationships. The last few years have seen a burgeoning of such efforts. Two excellent examples of this type of intervention are the Men as Partners or MAP project being conducted by the Planned Parenthood Association of South Africa in collaboration with AVSC International and the Stepping Stones program. Both programs seek to foster constructive roles for men in sexual and reproductive health. The curricula for these programs use a wide range of activities -- games, role plays, and group discussions -- to facilitate an examination of gender and sexuality and its impact on male and female sexual health and relationships, as well as to reduce violence against women. What is novel about these programs is that they target men, particularly young men, and work with them and women to redefine gender norms and encourage healthy sexuality. These are just two of an increasing number of innovative efforts to work with men, women, and communities. There is an urgent need now to rigorously evaluate the impact of these and other creative curricula in the settings for which they were developed and to find ways to replicate their use on a larger scale.

There is also a need to find ways to intervene early to influence the socialization of young boys to foster gender equitable attitudes and behaviors. Recent research conducted by Barker (forthcoming) in Brazil suggests that one way to do this is to study the many adolescent boys who do not conform to traditional expectations of masculinity. By studying these "positive deviants," Barker was able to identify a number of factors associated with gender equitable attitudes among young adolescent males. These factors include: acknowledgement of the costs of traditional masculinities, access to adults who do not conform to traditional gender roles, family intervention or rejection of domestic violence, and a gender equitable male peer group. These factors underscore the importance of male role models, within the peer group and the family, who behave in gender-equitable ways. More such creative research on masculinity and its determinants is necessary in order to identify the best approaches to promote gender-equitable male attitudes and behaviors.

Other programs that seek to transform gender relations include efforts to work with couples as the unit of intervention, rather than with individual women or men. Couple counseling in HIV testing clinics to help couples deal with the results of their tests and in family planning programs that promote dual protection against both unwanted pregnancy and infection are recent examples of efforts that seek to reduce the negative impacts of the gender power imbalance by including both partners in the intervention. Some programs, however, have reported difficulty in being able to find and recruit couples who are willing to participate, although many couples who do participate describe couple counseling as a positive experience. Research is needed to identify ways to overcome the barriers to couple counseling and to test the effectiveness of this method in creating more gender-equitable relationships and in reducing vulnerability and stigma.

Approaches that Empower

And finally, at the other end of the continuum -- far away from programs that foster damaging gender stereotypes -- are programs that seek to empower women. To know how to empower women requires us to deconstruct the sources or components of power that are amenable to project or policy intervention. From the research we have conducted, we have identified six sources of power: information and education; skills; access to services and technologies; access to economic resources; social capital; and the opportunity to have a voice in decision-making at all levels.

Thus, to empower women we must:

• Educate women. Give them the information they need about their bodies and sex. Information is power and women have the right to receive it.

• Give women the skills they need to use a condom. Make them condom literate. Provide skills training on communication about sex and foster interpartner communication.

• Improve women’s access to economic resources. Ensure that they have property and inheritance rights, have access to credit, receive equal pay for equal work, have the financial, marketing and business skills necessary to help their businesses grow, have access to the agricultural extension services to ensure the highest yield from their land, have access to formal sector employment, and are protected in the informal sector from exploitation and abuse.

• Ensure that women have access to health services and that they have HIV and STI prevention technologies that they can control, such as the female condom and microbicides. And support the development of an AIDS vaccine that is safe, effective, and accessible to women and young girls.

• Increase social support for women who are struggling to change existing gender norms by giving them opportunities to meet in groups, visibly in communities; by strengthening local women’s organizations and providing them with adequate resources; and by promoting sexual and family responsibility among boys and men.

• Move the topic of violence against women from the private sphere to the public sphere. This is not a personal issue it is a gross violation of women’s rights and is has significant negative implications for the health of communities and for economic development.

• And, to give women a voice, provide them with the opportunity to create a group identity separate from that of the family because for many women the family is often the social institution that enforces strict adherence to traditional gender norms; and promote women’s decision-making at the household, community, and national level by promoting women’s leadership and participation.

The Sonagachi sex worker project of West Bengal, India, is an excellent example of a project that sought to empower women through participation and mobilization. What began as an HIV/AIDS peer education program was transformed into an empowering community organizing effort that put decision-making in the hands of the most disempowered -- the sex workers (West Bengal Sexual Health Project 1996). How can we replicate Sonagachi in multiple sites worldwide? What are the ingredients that contributed to its success in mobilizing and organizing a disempowered community? Without the answers to these questions Sonagachi will remain the exclusive exception rather than the rule.

In the ultimate analysis, reducing the imbalance in power between women and men requires policies that are designed to empower women. Policies that aim to decrease the gender gap in education, improve women's access to economic resources, increase women's political participation, and protect women from violence are key to empowering women. We now have two international blueprints--the Cairo Agenda and the Beijing Platform for Action--that delineate the specific policy actions that are essential for assuring women's empowerment. Since governments worldwide have committed to these blueprints, it would be useful for the HIV/AIDS community to join hands with the international women's community to hold governments accountable for their promises by ensuring that the actions recommended in these documents are implemented. Creating a supportive policy and legislative context for women is crucial for containing the spread of the HIV/AIDS epidemic and mitigating its impact.

Conclusion

Let me conclude by urging all of us to ensure that the term empowerment of women becomes more than just a linguistic icon whose meaning is inversely proportional to its use! Empowering women and guaranteeing them their economic and social rights is not an option. In the AIDS epidemic it prevents deaths. It ensures that one of the greatest barriers to the health of populations and to economic development is eliminated – gender inequity. Empowering women is not a zero-sum game. Power is not a finite concept. More power to women does not translate into less power for men. Empowering women, strengthening their agency as actors and decision-makers in their own lives, and guaranteeing their rights increases the power of women, as well that of households, communities, and entire economies.

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