planning with services to prevent or treat sexually transmitted diseases
should be shaped by factors that influence women's access to services.
These factors are biological, economic, cultural and perceptual.
Network: Winter 1997, Vol. 17, No. 2
developing programs that integrate family planning with services to
prevent or treat sexually transmitted diseases (STDs), health care
providers should recognize factors that can influence women's access to,
or use of, reproductive health services:
STD transmission, including
transmission of the AIDS virus, may be easier from men to women than
from women to men because a large area of vaginal and cervical mucosa is
exposed to male sexual fluids during intercourse.1 STDs, which can be a
risk factor in acquiring HIV, are more often asymptomatic in women than
in men, so many women do not realize they have an STD. Family planning
clinics can help women evaluate their STD risks, recognize symptoms and
understand how to protect themselves.
For many women, sexual relationships
are often linked directly or indirectly to economic security. For
example, a woman may want to become pregnant because children provide
marital stability or status within the community.2 Consequently, she may
avoid using condoms despite a need for disease prevention. For some
women, sex is a means of economic survival. A study in Haiti, conducted
by FHI's AIDS Control and Prevention (AIDSCAP) project, found many women
feared that their partners would withhold money for rent, child care,
food and other items if they refused sexual relations.3 In the Dominican
Republic, researchers found that among women living in bateyes,
plantations where sugar cane is harvested, one-fifth had traded sex for
Cultural norms --
In many cultures, men are viewed as
authority figures, and women are discouraged from questioning their
partners' actions. "If you cannot talk to your partner about the
children's school fees, or where you are going to live -- if you cannot
ask the man where he is going when he leaves the house -- you definitely
cannot talk about condoms," says Dr. Maxine Ankrah of the AIDSCAP
In some societies, women are expected
to have one partner, while it is acceptable for men to have several
wives or to have partners outside of marriage. One young married woman
in Cambodia explained, "In Khmer society, it is nothing for men to have
other partners or a second wife because people compare the men to gold
and the women to cotton."5 Social taboos also discourage women from
talking or learning about sex, believing that ignorance is a sign of
Risk perceptions --
Because AIDS prevention programs have
often been targeted toward high-risk groups, including commercial sex
workers, many women do not perceive themselves at risk of HIV infection.
Research conducted in Brazil, supported by FHI, found that "although
women know how HIV can be transmitted, they do not perceive themselves
to be at risk because they are married or in a consensual union. Women
believe if they stay with one partner, they will be protected."6
Male latex condoms, the only
contraceptive recommended for protection against both viral and
bacterial STDs, are often viewed as a method that is used between casual
sex partners but not husbands and wives. In Thailand, approximately 70
percent of couples of reproductive age use some form of contraception,
but only 2 percent of married couples use condoms.7 If a woman suggests
condom use, her partner may suspect she is unfaithful -- or that she
thinks he is unfaithful. Researchers in Thailand found that among the
more than 700 men and woman interviewed, 60 percent said that condoms
should not be used with spouses or regular partners because it might
create tension or mistrust.8
-- Barbara Barnett
Guidelines for Implementing STD/HIV/AIDS Prevention and Care in
Reproductive Health Services.
Draft. Arlington: Family Health International AIDSCAP Project, 1996.
D'Cruz-Grote D. Prevention of HIV infection in developing countries.
Lancet 1996; 348: 1071-74.
PR, Cayemittes M, Metellus E. Haitian Women's Role in Sexual
Decision-making: The Gap Between AIDS Knowledge and Behavior Change.
Durham: Family Health International, 1995.
underscores need to empower women. The Daily Progress. July 9,
Patterson L. Men are Gold, Women are Cloth. A Report on the Potential
for HIV/AIDS Spread in Cambodia and Implications or HIV/AIDS Infection.
Phnom Penh: CARE International, 1994.
R, de Oliveira MR, Pinto P, et al. Empowering Women to Negotiate Safe
Sex: A Model from Brazil. XXIIth National Council for International
Health, Washington, DC, June 1995.
J. Chamratrithirong A, Debavalya N. Thailand's Reproductive
Revolution: Rapid Fertility Decline in a Third World Setting.
Madison: University of Wisconsin Press, 1987. National Statistical
Office. Report on the Survey of Population Change, 1991. Bangkok:
Sittitrai W. Thai Sexual Behavior and the Risk of HIV Infection: A
Report of the 1990 Survey of Partner Relations and Risk of HIV Infection
in Thailand. Bangkok: Thai Red Cross Society and Chulalongkorn