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“The only thing necessary for these diseases to the triumph is for good people and governments to do nothing.”






Integrating family 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



In 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:

Biology -- 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.

Economics -- 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 money.4


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 Women's Initiative.

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 purity.

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


1.        Guidelines for Implementing STD/HIV/AIDS Prevention and Care in Reproductive Health Services. Draft. Arlington: Family Health International AIDSCAP Project, 1996.

2.        D'Cruz-Grote D. Prevention of HIV infection in developing countries. Lancet 1996; 348: 1071-74.

3.        Ulin 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.

4.        Study underscores need to empower women. The Daily Progress. July 9, 1996.

5.        Phan H, 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.

6.        Badiani 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.

7.        Knodel 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: Np, Nd.

8.        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 University, 1992.