Multi-Country Study on Gender, Sexuality and Vaginal Practices

1. Multi-Country Study on Gender, Sexuality and Vaginal Practices IAS Satellite Symposium 20 July 2009Adriane Martin Hilber (ISPM - Switzerland) Terence Hull (ANU - Australia) Matthew Chersich (U.Gent - Belgium & RHRU- South Africa) for the GSVP Study Group

2. Classification of Vaginal Practices .. a variety of behaviours undertaken for diverse motives, with the common element that they involve some modification of the labia, clitoris or vagina. • Washing of external genitalia • Intravaginal cleansing (wiping/douching) • Application of (substances or steam) to external genitalia • Intravaginal insertion • Oral ingestion • Anatomical modification of vagina (surgery, traditional scarification or labial elongation)

3. Study objectives • What is the prevalence and frequency of vaginal practices within each study population? • What are the reasons women undertake these vaginal practices? • What impact do these practices have on women’s and men’s self-perceived sexual satisfaction and experience? • What impact do these practices have on women’s and men’s self-perceived reproductive health? • To what extent are the practices promoted by women’s sexual partners, or by other members of the community, including traditional and modern health service providers?

4. Project Overview • Phase 1 (2004-06) Qualitative Study to improve understanding of the nature, motivations and circumstances of these complex practices • Phase 2 (2006-2007) Household Survey to determine the population-level prevalence of practices, and the intended and adverse effects of practices • Study in Mozambique (Tete), South Africa (Kwa-Zulu, Natal), Indonesia (Yogyakarta), & Thailand (Chonburi); Kenya in 2009-2010

5. GSVP Survey Methods (1) • Phase 1 qualitative: Key Informant & In Depth Interviews; FGDs – results informed the questionnaire • Phase 2 Household Survey: • 850 randomly selected women 18-60 years • multi-stage cluster sample design • clusters were census enumeration areas (+/-100 HH) • HH selection per cluster: 20/Asia, 30/Africa • generic structured questionnaire; with local adaptations and additional categories

6. GSVP Survey Methods (2) • Descriptive analysis of practices characteristics within a standard framework • Multivariate analysis to identify population groups with high levels of practices • Study estimates were weighted for differential probabilities of inclusion and response. • WHO and local ethical approvals

7. Qualitative findings • Vaginal Practices are motivated by: • Desire for improvedsexual relations to tighten, warm, close or dry the vagina (e.g.Dry Sex) • hygiene (e.g. douching, washing, cleansing, steaming, application) and are done in association with specific life events (e.g. menses, marriage, child birth, menopause) • health (e.g. to eliminate discharge, self treat a suscepted STI, induce an abortion) • Women use a variety of products (natural and commercial preparations) in their vaginal practices • Frequency of practices varies depending on motivation, product used, life event, desired effect

8. Framework for measuring vaginal practices

9. Prevalence

10. Prevalence of practices-African sites Mozambique n=1025 South Africa n= 867

11. Adverse events Mozambique

12. Adverse events South Africa

13. Conclusions

14. General Patterns • Hygiene • Cleanliness • Odor • Health • Disease prevention, control or treatment • Sexuality • Competition for sexual partners among young women • Competition against young women among married middle aged women • “Performance enhancement” • Self-fulfillment – less clear

15. Tightening or drying? • Friction favored by both men and women • This could be achieved through warming, tightening, closing (or elongated labia in Mozambique) • “Dryness” per se was only intended where there was obvious wetness to such an extent that the partner complained of infidelity or discomfort

16. Health Implications • Life-time experience of side effects common, and asymptomatic genital lesions or inflammation are likely even more common. Genital bleeding and sores more frequent in Asian sites though the higher prevalence of practices in Africa makes side effects here more concerning • Women are less likely to use a condom or other barrier methods for contraception or for dual protection as most practices imply ‘skin to skin’ contact • There was significant use of a myriad of practices to address other SRH concerns including induced abortion and self treatment of vaginal discharge and other symptoms of STIs

17. Acknowledgements of partners and funders • Partnering organisations – ANU (Australia), CRDS (Mozambique), ICRH (Kenya & Mozambique, Beligum), ISPM (Switzerland), Mahidol University (Thailand), RHRU (South Africa), Women‘s Health Foundation (Indonesia), WHO • Funders – AUSAid,Australian National Research Council, Flemish Government, Ford Foundation, International Partnership for Microbicides, UNAIDS, USAID, WHO

18. Asia Indonesia Team • Ninuk Widyantoro, Women’s Health Foundation • Herna Lestari , Mintra Inti Foundation • Laily Hanifah, Mintra Inti Foundation • Besral Madras, Mintra Inti Foundation • Iwu Utomo, Australia National University Thai Team • Aree Prommho, Institute for Population and Social Research, Mahidol University • Kullawee Siriratmongkon, Mahidol University • Susinee Worasrisothon, Mahidol University • Chintana Wacharasin, Faculty of Nursing, Burapha University • Monruedee Lapimon, Thai Women AIDS Task Force

19. Africa Mozambique Team • Brigitte Bagnol, ICRH Mozambique (consultant) • Esmeralda Mariano, Eduardo Mondlane University • Francisco Mbofana, CRDS/MISAU • Isabel François, ICRH Mozambique (consultant) • Elise Kenter, ICRH Mozambique (consultant) • Hipolito Nzwalo, Ministry of Health, Mozambique (MISAU) South Africa Team • Jenni Smit, RHRU • Busi Kunene, RHRU • Ntsiki Manzini, RHRU • Matthew Chersich, RHRU/ICRH • Mags Beksinska, RHRU