Contents
Chapters
- The Invisible Epidemic
- How Young People Become Infected
- Why So Vulnerable?
- Adolescent Behavior Increases Vulnerability
- Lack of Information
- Norms and Expectations
- Poverty and Deprivation
- Social Intolerance and Discrimination
- Addressing the Epidemic
- Reaching Out
- Consequences of Inaction
- HIV/AIDS: What Young People Want to Know
- Profiles
- Youth at the Center
Highlights
- Why young women face more risk
- Culture can hurt
- Profile: Going public
- Education should start early
- Condoms for dual protection
- Orphans: A new challenge
- What can parents do?
- Reaching street children
- Putting youth at the center
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Published by the Population Information Program, Center for Communication Programs, The Johns Hopkins University Bloomberg School of Public Health, 111 Market Place, Suite 310, Baltimore, Maryland 21202, USA.
Volume XXIX, Number 3
Fall 2001
Series L, Number 12
Issues in World Health
Norms and Expectations
At the outset of the crisis in the early 1980s, AIDS was defined as a problem of individual behavior. Today, however, as the epidemic reaches catastrophic proportions, it is widely recognized as an enormous social crisis as well. Social norms and expectations and community attitudes and policies toward the roles and behavior of young men and women contribute to their risk for HIV/AIDS and make it more difficult to address the epidemic. Some traditional cultural practices add to the risk (see side-bar How Culture Can Hurt).
Often, a double standard prevails about sexual behavior (39, 125, 221, 426). Virginity is the traditional norm for unmarried girls, while young men are expected to seek sexual adventure. Fearing that they will be admitting to sexual activity, many young women cannot ask for information about sex or protect themselves (299). In Brazil and some other countries, married men's infidelity is considered normal and acceptable (98). Among the Zulu of South Africa, the term for a man with many sexual partners, isoka, is the ultimate compliment. In a recent study, news that one of the respondents had fathered a third illegitimate child was greeted with relief by his family as evidence that he had demonstrated beyond doubt his isoka status (381).
In some societies young women as well as young men are expected to be sexually experienced. In some West African communities virginity is considered to be unmodern, anti-social, and unhealthy, and virgins are considered to be "frigid" (321). In Cameroon norms of sexual activity among adolescent girls are so strong that virgin girls tend to be scorned both by men and women. People feel that, so long as a young woman is not promiscuous, premarital sexual experience enhances her prospects for marriage (238).
Poverty and Deprivation
AIDS is now largely a disease of deprivation (403, 410). A World Bank analysis of 72 countries shows that at the national level both low per capita income and unequal distribution of income are associated with high rates of HIV infection. Among urban adults in the typical developing country, a US$2,000 increase in per capita income is associated with an HIV infection rate 4 percentage points lower (7).
In a climate of deprivation young people, and especially young women, are at particular risk. In Kenya, for example, adolescent women from poor and unstable family environments were more likely than women from better family environments to have had sexual experience (189). In Ecuador sexual risk-taking by adolescents was more common among families with only one income earner than in those with two or more (109).
In many countries young women, lacking opportunities, seek support from men, trading sex—and thus the risk of contracting HIV infection—for security. The risks are greater when the men are older. In Tanzania, for example, where growing poverty has made traditional marriages more difficult to arrange, young women compete for the attention of older men, who are better established than young men and thus more attractive as potential husbands (205). Often, this practice is driven by parental expectation of financial support from their children (434). Similarly, in Nicaragua economic upheavals have caused many young women to prefer older men who can take better care of them (426).
Although the motivations for this are complex (434), young women sometimes enter into relationships with older men—called "sugar daddies" in sub-Saharan Africa—who pay their school fees, buy them gifts, and offer other inducements (205, 238, 255, 315, 434). Other young women establish similar relationships with young men (134, 205, 255, 267). In South Africa many young women have sexual relationships in exchange for favors, gifts, and cash (217). A few studies report similar arrangements between young men and older women, as in Cameroon and South Africa, where some young men have "sugar mummies" (238, 322).
Economic hardship and civil unrest have pushed more and more young men and women away from home and into towns and cities to look for work. Many enter multiple sexual relationships that carry risk for HIV and thus transmit the virus from one place to another (111, 247). Female migrant workers—many of them unmarried girls in domestic or seasonal work—are often sexually exploited (277). Poverty and lack of alternatives also are major reasons that many children become sex workers (31, 37, 137, 176, 219). In some Asian countries young women enter the sex trade with the sanction of parents, in order to send money home (56, 202).
Social Intolerance and Discrimination
When societies do not recognize that young people share the same human rights as adults, they make young people more vulnerable to intolerance and discrimination. Policies toward youth often reflect adult views of what young people should and should not be doing, not what young people really need. For example, discriminatory policies do not respect young people's need for medical confidentiality and may restrict access to information (127, 361). Many young people who have been tested positive for HIV have learned of their status not from health care providers but from their parents, who have been informed without the young person's consent (130).
Prejudice based on sexual orientation and discrimination due to HIV status further fuel the AIDS epidemic (162). Many societies contribute to the spread of HIV/AIDS by stigmatizing, and often outlawing, homosexual behavior (55). Until recently, the Catholic Church in Ireland did not recognize the existence of homosexuality, and thus health officials did not respond to cases of AIDS among gay men (336). In the US the initial labeling of HIV/AIDS as a "gay disease" distanced the rest of society from the epidemic and made it difficult to obtain government funding for prevention programs in the early 1980s (97). Such attitudes particularly affect youth experimenting with or coming to terms with being bisexual or gay—leading to sex in a climate of secrecy or shame (283).
