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5. Gender, sexuality and sexual health: Pathways beyond awareness
   Last updated: 29.06.02
 
Gender, sexuality and sexual health are known to be significant determinants of vulnerability to HIV. Equally, attention to these issues are key pathways beyond awareness raising.

Despertando is a women’s community group working in El Guasmo, a poor urban community on the outskirts of Guayaquil, Ecuador, with the support of the linking organisation COMUNIDEC. It began its workshops for community members with basic sexual health, gender and sexuality education, as well as attention to specific issues identified as priorities by the community - such as violence against women and sex education for young people. As one community member said of the workshops: “They used our language rather than technical words, and helped us to communicate. It was very important for me because I learned things I didn’t know about my own body and my own health. I’ve learned how to teach my children about issues such as sexual health and AIDS.”

NGOs at the country seminars of “Community Lessons, Global Learning” shared that their participatory community assessments highlighted for them the key role that gender plays in determining access to and quality of sexual health service provision. Ms. Anjuman Ava, a community educator with ACD in Bangladesh reports that: “Women don’t like to talk to male doctors, so they don’t share their concerns, and go without treatment or advice.” In Sri Lanka, Sewalanka found that their needs assessment revealed “Gender imbalance as a key area. Women’s needs are neither recognised or considered.” Meanwhile, for other NGOs the act of conducting participatory community assessments raised awareness of gender. As one reported: “Once the men had left, the women’s discussion was very wide ranging. It revealed concerns about sexual health which had been denied in the mixed meeting.”

The importance of a gender-sensitive assessment practice was stressed during all the country seminars, with groups sharing their success at encouraging single sex discussion groups and same sex facilitators. Some NGOs reported how increasing gender awareness led to changes in staffing. For example, ACD hired two female staff members to work with the young women being trafficked across the Bangladeshi-Indian border. Despertando, too, was sensitive to gender dynamics when planning its sexual health workshops with the community in Guayaquil, Ecuador, beginning with all-female workshops before broadening out to include male partners and young people. The difficulty of working in mixed groups on these issues became evident, highlighting the importance of basic communication between women and men.

Problems of male-female communication were also a focus of discussion in Cambodia. In response, KHANA has developed an experiential exercise for use with community groups to explore how gendered messages and practices during childhood create both barriers to communication between women and men and the gender hierarchy of power on which so much of women’s vulnerability is based. But these problems of communication are related more generally to the problems of discussing sex and sexuality in the cultures in which the Alliance works. This sexual silence not only applies between men and women but also across the generations. Samadeepa Samaja Kendraya, a Sri Lankan NGO, notes that “there is a culture of reticence about talking of sex which prevents parents from giving information to their children.”

Nor has it been easy for some of the Alliance’s partners to end the silence and openly discuss sex and sexuality. “In the beginning it was very hard for me, particularly as a woman, to talk about these type of sensitive issues,” says Ms. Anjuman Ava, community educator with ACD in Bangladesh. Her male colleague, Md. Towhidul Alam, adds: “When I first started this work in sex and sexuality issues, I was very concerned about my status and what people would think.” With the technical support of HASAB, the staff of ACD have been able to reflect on and change their practice: “We learned alot from Kabita [the HASAB Programme Co-ordinator] about how to talk openly about sensitive issues such as masturbation.”

The Alliance is also adapting and refining experiential and participatory groupwork exercises which explore related issues. These include identifying and ranking problems of sex, discussing the gender-related expectations and exercise of power in sexual situations, and developing skills in assertiveness and sexual negotiation. The transformative power of this group discussion approach is apparent in the work of Despertando in Ecuador.

It has been clear from “Community Lessons, Global Learning” seminars that there is an on-going need to strengthen the skills and concepts required to address sexuality during participatory community assessments. “We now know that homosexuality is a reality,” said one staff member of Samadeepa Samaja Kendraya after an Alliance Lanka workshop. The value of sexuality-sensitive assessments is also apparent in their descriptions of the diversity and specificity of male-to-male sexual experiences, from established gay cultures to situational male-to-male sexual encounters in all-male environments (such as military camps and prisons). The importance of documenting and discussing sexual diversity is evident in the work of FAES, a community group run by transvestites for transvestites in Quevedo, Ecuador. As Dr. Lilly Marquez, a COMUNIDEC consultant providing on-going technical support, notes: “The community has accepted what they are doing - partly because they have learned that many of the local men - even when married - have sexual relations with transvestites.”

These issues take on special significance in low HIV prevalence countries, where issues relating to STDs, reproduction and sexual violence are of more immediate concern to communities than HIV/AIDS. It has also helped to draw attention to the ways in which communities themselves locate the HIV and AIDS information they receive within their own belief systems about sickness associated with sexual and reproductive organs. In Cambodia, for example, the Khmer term for AIDS is the same as that for syphilis, which is linked to the exchange of ‘bad blood’, transmission of which has a moral and spiritual, and not merely biological, quality. Thus KHANA has encouraged its partner NGOs to work with the Kruu Khmer (traditional healers) - not only as key informants in project planning, but also as partners in sexual health information provision in order to help to make sense of information about HIV and AIDS within traditional Khmer disease models.

Many of the Alliance’s partner NGOs have described how they locate HIV work within their broader mandate for sexual and reproductive health. A number of NGOs in Bangladesh, for example, combine clinic-based and outreach STD services. While, in Sri Lanka, NGOs report that family planning concerns frequently provide an entry point into HIV prevention work, for both men and women. As Sabe Mithuro, a Sri Lankan NGO targeting male trainee police officers, reports: “The issues which arose were needs for information about family planning, condom use and sexual health in general.”

The quality and accessibility of appropriate services has been a central concern within the Alliance’s sexual health, gender and sexuality framework for HIV prevention. Improving access by taking services to where potential service users are, has been a common approach. As Mr Tariqul Islam of CEDAR, an NGO working with truck drivers at Aricha Ghat, Bangladesh, notes: “By combining outreach work with services, we’re aiming to provide a full ‘package’ of support for our community - of STD treatment and medicine, but also of health education, condoms, and advice.” While, in Senegal, ANCS has supported Amicales de Jeunes de Liberté to promote social marketing of condoms as part of community outreach with young people in Dakar.

Case study: Focusing on gender and sexuality among poor, urban women, Despertando, Ecuador
“Sometimes the men would act like they were the ones in authority which was difficult for the women facilitating. There were some men who didn’t want to know the information and who wouldn’t let others talk, but we tried to cope with the situation. We raised issues about communication between men and women, and children and parents.”
A member of Despertando describing their family workshops.

Comment
“We don’t just need to learn the facts about AIDS, but also how we can protect ourselves. We don’t want to stop having sex, but we do want to learn how to do it safely. We need to be able to discuss these things - because in our culture we don’t talk about sex. Here, we can talk openly about what’s on our mind, get condoms and learn about ways to take care of ourselves.”
Chaminda, 26 year old “beach boy” at Unawatuna, involved in a project by Saviya, an NGO supported by Alliance Lanka

Transformative groupwork in Ecuador
“Before I was a shy person and didn’t like to talk in case I said anything wrong. Working with Despertando I learned about my own sexuality and sexual health. I learned about my body and about being a woman, as well as about issues such as HIV/AIDS. I learned that I have rights as a woman and as a member of my community....I had my own ideas and thoughts, but I never said them out loud. Now I’ve learned what it is to be a woman as well as a wife and a mother...Now I have the confidence to know what I want and to speak out.”
Elsa Almendaris describing the benefits of Despertando’s groupwork strategy

The realities of male power
“The police school was selected because of concerns about the misuse of power by male officers and the impact of this on sexual health of the officers, their families and communities where they work. An additional concern is the alleged involvement of the police in taking money from brothels and sex workers. This gives them some de facto control over the sex industry.... Allied to this is a general need for gender awareness to counteract the subjugation of women by police officers.”

Extract from a report by Sabe Mithuro, a partner NGO of Alliance Lanka, Sri Lanka

Lessons learned and future challenges
For all of the difficulties inherent in addressing gender, sexuality and sexual health, these are the areas where NGOs are clearly making the most progress in responding effectively to HIV/AIDS. The lessons learned include:

  • NGOs benefit enormously from technical support which helps them to integrate a conceptual understanding of sexual health, gender and sexuality into all aspects of organisational policy and programmatic practice. These include recruitment and personnel policies, selection and training of technical support providers, and all stages of project design, implementation and evaluation.


  • Participatory community assessments have identified the widespread need for gender-sensitive service provision and the reality of sexual diversity in many communities. Women’s needs are frequently neglected in the design and delivery of sexual health services; recruiting more female staff has improved the ability of partner NGOs to conduct assessments and provide services which address women’s needs. In addition, HIV prevention in the context of sexual diversity must address heterosexist and homophobic attitudes and practices, both external and internal.


  • Effective strategies both respect and challenge cultural restrictions on discussion of sex and sexuality, and acknowledge realities which are frequently denied in mainstream culture - such as sexually active young people and male-to-male sex.


  • Participatory groupwork is a promising response to the basic lack of communication about sex, sexuality and sexual health in the societies in which the Alliance works. These approaches merit careful evaluation as to their impact and potential for scaling up. This is especially the case given their dependence on sophisticated facilitation skills and the consequent need to strengthen skill development in this area.


  • There is a need to develop new strategies to work with young people on sexuality and, in particular, to adopt a harm reduction approach which works with the reality of young people’s sexual experience (and desire for it) to promote its safety. This is related to an overall dearth of appropriate operational research on sexuality, and to a lesser extent, gender.


  • The Alliance must seek to increase its work in partnership with broader movements for gender and sexual justice - in order to challenge laws and policies which preserve or ignore the social inequalities at the heart of the HIV epidemic. Coerced sex and histories of sexual abuse are other realities which impinge on sexual health. There is a need for the Alliance and other agencies to strengthen their ability to identify and respond to these realities as a part of HIV work.


Source: Beyond Awareness Raising
This is an extract from Beyond Awareness Raising: Community lessons about improving responses to HIV/AIDS, published by the International HIV/AIDS
Alliance in 1998.

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