Rachel C. Snow

The association between female genital cutting and correlates of sexual and gynaecological morbidity in Edo State, Nigeria

Sir, We feel that the conclusion of Okonofua et al. that female genital cutting ‘did not attenuate sexual feelings’ is a dangerous over-interpretation of their results. The authors do not acknowledge the difficulties inherent in gathering data on sexual pleasure. Their conclusions are based in part on responses to structured questions about frequency of orgasm and sensitivity of body parts that make many assumptions about women’s understanding of sexual pleasure, anatomy and willingness to answer such questions. There is no discussion of the validity of the responses to these questions or the subtle ways in which sexual experiences might be understood and reported differently by cut and uncut women. The authors also ignore the fact that women may initiate sex for reasons other than sexual pleasure, such as in order to conceive and that pressures for high fertility may be stronger among cut women. Nor do they mention the possible bias inherent in the inclusion only of women attending family planning and antenatal clinics (i.e. sexually active women). The authors describe symptoms of genital infection as ‘robust’ indicators of sexual activity, even while acknowledging the poor correlation between these and laboratory diagnosed conditions. Even if symptoms do give some indication of actual infection, other studies in West Africa show these to consist mainly of the endogenous conditions bacterial vaginosis and candida rather than the sexually transmitted infections chlamydia or gonorrhoea. Finally, if differences between cut and uncut women in prevalences of those reporting symptoms did indicate differences in prevalence of sexually transmitted infections, this might imply differences in sexual behaviour patterns or biological susceptibility to infection but would not allow conclusions about sexual fulfilment or feelings. Therefore, while we agree that there is no suggestion from the data that cut women are less sexually active or less susceptible to genital infections or pregnancy at an early age than uncut women, the conclusion that female genital cutting does not attenuate sexual feelings does not follow. Finally, even if the conclusion that female genital cutting does not attenuate sexual feelings appears to undermine the arguments of traditional defenders of female genital cutting, it also undermines the efforts of anti-cutting advocates. Researchers in this sensitive area must be careful to interpret data objectively rather than meet advocacy needs.

Gender, Migration and HIV in Rural KwaZulu-Natal, South Africa

Objectives Research on migration and HIV has largely focused on male migration, often failing to measure HIV risks associated with migration for women. We aimed to establish whether associations between migration and HIV infection differ for women and men, and identify possible mechanisms by which womens migration contributes to their high infection risk. Design Data on socio-demographic characteristics, patterns of migration, sexual behavior and HIV infection status were obtained for a population of 11,677 women aged 15–49 and men aged 15–54, resident members of households within a demographic surveillance area participating in HIV surveillance in 2003–04. Methods Logistic regression was conducted to examine whether sex and migration were independently associated with HIV infection in three additive effects models, using measures of recent migration, household presence and migration frequency. Multiplicative effects models were fitted to explore whether the risk of HIV associated with migration differed for males and females. Further modeling and simulations explored whether composition or behavioral differences accounted for observed associations. Results Relative to non-migrant males, non-migrant females had higher odds of being HIV-positive (adjusted odds ratio [aOR] = 1.72; 95% confidence interval [1.49–1.99]), but odds were higher for female migrants (aOR = 2.55 [2.07–3.13]). Female migrants also had higher odds of infection relative to female non-migrants (aOR = 1.48 [1.23–1.77]). The association between number of sexual partners over the lifetime and HIV infection was modified by both sex and migrant status: For male non-migrants, each additional partner was associated with 3% higher odds of HIV infection (aOR = 1.03 [1.02–1.05]); for male migrants the association between number of partners and HIV infection was non-significant. Each additional partner increased odds of HIV infection by 22% for female non-migrants (aOR = 1.22 [1.12–1.32]) and 46% for female migrants (aOR = 1.46 [1.25–1.69]). Conclusions Higher risk sexual behavior in the context of migration increased womens likelihood of HIV infection.

Female genital cutting in southern urban and peri-urban Nigeria: self-reported validity, social determinants and secular decline

Despite growing public resistance to the practice of female genital cutting (FGC), documentation of its prevalence, social correlates or trends in practice are extremely limited, and most available data are based on self‐reporting. In three antenatal and three family planning clinics in South‐west Nigeria we studied the prevalence, social determinants, and validity of self‐reporting for FGC among 1709 women. Women were interviewed on social and demographic history, and whether or not they had undergone FGC. Interviews were followed by clinical examination to affirm the occurrence and extent of circumcision. In total, 45.9% had undergone some form of cutting. Based on WHO classifications by type, 32.6% had Type I cuts, 11.5% Type II, and 1.9% Type III or IV. Self‐reported FGC status was valid in 79% of women; 14% were unsure of their status, and 7% reported their status incorrectly. Women are more likely to be unsure of their status if they were not cut, or come from social groups with a lower prevalence of cutting. Ethnicity was the most significant social predictor of FGC, followed by age, religious affiliation and education. Prevalence of FGC was highest among the Bini and Urhobo, among those with the least education, and particularly high among adherents to Pentecostal churches; this was independent of related social factors. There is evidence of a steady and steep secular decline in the prevalence of FGC in this region over the past 25 years, with age‐specific prevalence rates of 75.4% among women aged 45–49 years, 48.6% among 30–34‐year olds, and 14.5% among girls aged 15–19. Despite wide disparities in FGC prevalence across ethnic, religious and educational groups, the secular decline is evident among all social subgroups.

Determinants of HIV counselling and testing participation in a Prevention of Mother-to-Child Transmission programme in rural Burkina Faso

Objectives  To analyse the factors associated with the uptake of HIV counselling, HIV testing and returning for test results in a rural hospital setting in Nouna, Burkina Faso.

Power and decision: the social control of reproduction.

This book is a collective effort to provide in one publication an overview of the disparate social forces that circumscribe reproduction within specific social parameters with a complementary examination of how biomedical research and the new reproductive technologies reflect and sustain those parameters. Including case studies from a range of countries this book offers a collection of Southern and Northern feminist perspectives on which social controls offer protective support for parenting and suggestions on how to redress those which do not. The chapters in this volume illustrate both the commonalities and disparities between first and third world settings. (EXCERPT)

The Role of HIV-Related Knowledge and Ethnicity in Determining HIV Risk Perception and Willingness to Undergo HIV Testing Among Rural Women in Burkina Faso

We conducted a random community based survey of 300 young (15–29 years) rural women in Nouna, Burkina Faso. Only one-third of women were aware that a person could have HIV without having symptoms and these women were significantly more likely to classify themselves to be at high risk for getting HIV. Furthermore, multiple partners, Bwaba ethnicity and having mentioned a health worker as a source of HIV information were significantly associated with perceived high personal risk. Perceived willingness to participate in VCT was high (69%). The dissemination of information on the asymptomatic nature of HIV infection could potentially be very important in forming risk perception, awareness, and their willingness to participate in HIV interventions.

Are men testing? Sex differentials in HIV testing in Mpumalanga Province, South Africa

Abstract HIV testing is the centerpiece of the national AIDS program in South Africa and many HIV-endemic countries, yet there is surprisingly little published data on who uses testing services. In 2006, we conducted a census of HIV-testing records in all 282 public and non-governmental voluntary counseling and testing (VCT) sites in Mpumalanga (MP), South Africa, the province with the highest HIV prevalence in the country. We secured data on the age and sex of all those tested in 260 sites since the year testing was initiated, as far back as 1998 in some sites. For the year 2006, we also secured data on whether a client came to VCT through self-referral, antenatal services (prevent mother-to-child transmission (PMTCT)), or medical referral. The results characterize the rapid uptake of testing as facilities increased, with the number of people testing in MP more than doubling each year between 2002 and 2006. However, there is a persistent 3:1 differential of females:males testing, with 72.7% of all testing among females. When pregnancy-related testing (via PMTCT) is excluded, females still account for 65.1% of all testing in MP. The data also suggest men are more likely to test at older ages and as a result of medical referral. In summary, females in MP are far more likely to use HIV testing than males, even after accounting for increased access to testing during pregnancy. Sex differentials in HIV testing warrant closer policy attention.

Integration of prevention and care of sexually transmitted infections with family planning services: what is the evidence for public health benefits?

It has been widely believed that, by combining the services for preventing and treating sexually transmitted infections (STI) with those for family planning (FP), STI coverage would increase and the combined service would be of higher quality and more responsive to the needs of women. So far, there is little concrete evidence that integration has had such an impact. Besides the absence of documentation, a clear definition of integration is lacking. We therefore carried out a comprehensive review of concrete experiences with integrated services, and present a summary of our findings in this article. The results indicate that the tasks of STI prevention, such as education for risk reduction and counselling, have been integrated into family planning services much more frequently than the tasks of STI diagnosis and treatment. Some STI/FP integration efforts appear to have been beneficial, for instance when the integration of STI/HIV prevention had a positive impact on client satisfaction, and on the acceptance of family planning. Less clear is whether STI prevention, when concentrated among traditional FP clients, is having a positive impact on STI risk behaviours or condom use. A few projects have reported increases in STI caseloads following integration. In some projects, FP providers were trained in STI case management, but few clients were subsequently treated.

Balancing effectiveness, side-effects and work: women's perceptions and experiences with modern contraceptive technology in Cambodia

This community-based study presents the results of 17 focus-group discussions primarily among poor married women of reproductive age in urban and rural Cambodia regarding their experiences with modern contraceptive methods and their preferences for different technical attributes, including effectiveness, mode of administration, secrecy and rapid return of fertility. Key findings indicate that women who use modern contraceptive technologies desire highly effective methods of birth control. Cambodian women are primarily interested in longer-acting methods, view weight gain positively and are less concerned about a rapid return to fertility upon discontinuation of a method or secrecy from their partners. Women report a high level of side-effects as well as a high level of individual variation between side-effects and each modern contraceptive method used. Women with more knowledge and experience of modern contraceptive technologies alter their preference for highly effective methods based on a methods perceived suitability. Specifically, women may switch from a modern method associated with negative side-effects to a lesser effective traditional method, either to take a break from unwanted side-effects or discontinue modern methods altogether, if another suitable method is unavailable. These and other findings point to the need for greater development and choice of contraceptive methods with different technical attributes; improved information that clearly and simply describes how each method works within a womens body and its expected side-effects; improved access to reproductive health services; and improved assessment of womens underlying burden of reproductive illness not directly associated with modern contraceptives.

Sex, gender, and vulnerability

Abstract This paper is concerned with how sex chromosomes and gendered experience differentially contribute to health outcomes, and how gender effects provide an under-explored avenue for health intervention. Research on gender and health is currently undermined by conflation of sex and gender in much of the epidemiologic and clinical literature. This precludes any meaningful reflection on the extent to which our genetic blueprint, versus gendered socialization, contributes to the specific health vulnerabilities of males or females. Drawing on the 2002 global disability adjusted life years (DALYs) for males and females, this paper looks at health outcomes that differentially affect males and females, and distinguishes between vulnerabilities linked to the XX or XY genotype, vulnerabilities due to gendered life experience, and vulnerabilities about which we understand relatively little. The paper highlights the dynamic and changeable nature of gendered health vulnerabilities. Given that gender-based risks are, in principle, amenable to social change, they offer untapped potential for health interventions.