Pumla Ntlabati Presented at the 6th SA AIDS Conference

1. Cultural constructions of womanhood in South Africa and implications for health interventions20th June 2013 Pumla Ntlabati Presented at the 6th SA AIDS Conference Co-authors: Helen Hajiyiannis; Tselisehang Motuba; Richard Delate; Lusanda Mahlasela

2. Background and Context • In partnership with Johns Hopkins Health and Education in South Africa and its partners (JHHESA), CADRE conducted research to examine societal constructs of womanhood, especially those that place pressure on women to conform, putting their health at risk. • Findings would inform design and content of the national Women and Girls’ campaign, aimed at empowering women to get a sense of the kind of strength that will enable them to draw their own boundaries, and to take control of their lives, their health and their futures. • The campaign aims to move beyond HIV interventions to encompass sexual and reproductive health (SRH) issues, and focuses on teenage pregnancy, sexual reproductive health (family planning) and Prevention of mother-to-child transmission (PMTCT). • The campaign is evidence-based, is informed by research, and is also in line with international sexual and reproductive health guidelines and developmental goals pertaining to women.

3. Objectives • To examine local and cultural perceptions of womanhood; • To understand how society, and how women define themselves; • To understand how the role of women has historically been determined (often within cultural boundaries); • To understand how societal constructs of womanhood can be perpetuated by men and women; • To examine beliefs and ideas about the essence of femininity and perceptions and expectations of women across South Africa; • To understand how these definitions impact on choice and utilisation of opportunities to control women’s own health outcomes.

4. Methodology • Five focus groups were conducted in four South African provinces. • The provinces included equal representation of women living in urban, peri-urban and rural localities. • Males were included in two of the five focus groups. • Focus group participants were aged 20 to 40 years. • Groups were conducted in: Welkom (Free State), Maruleng (Limpopo); Johannesburg (Gauteng), Umlazi and Bulwer (KwaZulu-Natal).

5. Sample discussion questions • Who is considered a woman in your community? • What does it mean to be a woman? • What is your understanding of the roles of women? • What is expected of women in this community? • How do women in this community talk about their sexuality? • What are community expectations of women and motherhood? • Who determines how many children a woman has and when she has them? • What challenges do women in your community face? • What kind of issues that affect women would you like to see addressed? • Where do women get their strength from or what is the source of a women’s strength? • How do women show their strength? How do women NOT show their strength? • What are advantages and disadvantages of women being on contraceptives? • What are the attitudes in this community towards women who are on contraception? • What is the best way to communicate information about contraception to women?

6. Defining women • Definitions of a woman appear similar across all sites, with specific values and behavioural attributes attached to them. • These include age, physical and emotional development, behaviour/deportment, dress, and values exuded. • I think a person is a child before they reach that stage of being a woman, it starts by physical changes thereafter... The body develops breasts and other changes, and basically at that stage a person realises that they have to change, due to these physical changes they have to adjust how they behave as a woman, because there is a difference between a girl and a woman (Female, age 25, urban, KwaZulu-Natal). • Maturity as defined by experience, as opposed to age, also appears to be a determining factor (e.g. children heading households). • I think it’s like different experiences that shape you to become a woman, because different people go through different things, and we all like grow and mature at different stages. So I mean a 19 year old girl could be more mature than a 25 year old woman just because of the things that she’s been through” (Female, age 20, urban, Gauteng). • Both men and women appear to subscribe to these values & determinants.

7. Who determines when and how one enters womanhood? • Determinants of womanhood are mostly imposed by the community one grows up in. • …as you grow older you get taught specific teachings that help you grow up into womanhood. When you enter into puberty you are taught that you need to dress in a certain way, you will not play with boys and all those things. …When you walk, you need to exude pride and show your positive upbringing…. because a woman should behave this way... • …the way she behaves, the stuff she does, where she goes, who she hangs out with, how she talks”. A well-mannered woman would “go to movies, have lunch with friends, not go partying late, or doing something bad like drugs and everything” (Male, age 22, urban, Gauteng). • Both the parents and the community hold a supervisory role in terms of what is regarded as acceptable and what is not. • When I was growing up, my father did not allow me to wear trousers even though wearing trousers was fashion that time, he said I should dress like a girl (Female, age 34, peri-urban, Free State). • When I was young I was chubby, a fat child, I realised that my mom wanted to dress me up in clothes that covered me up because I had a big body, she explained that my body is not the same as of that of my peers, because men are naughty now, in order to prevent any mishap you need to cover up your body (Female, age 25, urban, KwaZulu-Natal).

8. Defining role & expectations • Formal and informal teaching of women about how to be a woman are carried on through the stages of life: young girl; young woman; getting married; becoming a mother etc. • Dignity; being strong, selfless, putting up with adversity, putting others before self always; submissive to husband, have children; don’t talk about issues; keep own pain hidden from children and others. • I think a girl becomes a woman when she starts becoming selfless… like usually when you’re a girl, all you’re thinking about is …looking a certain way …and then that changes when you become a woman and you start, I don’t know, putting other people first... (Female, age 20, urban, Gauteng). • These values appear to survive through being passed on to girl children by mothers as a way of ensuring that they know what is expected of them as they take up their place as women. • When my sisters and I became teenagers, she sat us down and told us what it means to be a woman, and she said, one thing that stuck to me was she told us to always be strong. As a woman, you must always be strong. You must know how to just get over things. Don’t ever try to act like a man; you must always be a woman (Female, age 20, urban, Gauteng).

9. Defining role & expectations • Evidence of traditional notions of expectations and roles of women was common across all groups; researchers had to sift through layers of data and probing to get to ‘actual lived experience. E.g. Women are seen to play a vital role in ensuring the smooth running of the home. • I think for example with me, like with my girlfriend, I would expect her to do the cooking, I can’t cook, do the cooking and cleaning and stuff like that. Obviously I would help her out now and again, but it’s because when I was growing up, my mom used to do that for me. So what my mom did for me, I expect a woman, my wife or girlfriend or whatever, to basically do (Male, age 24, urban, Gauteng). • You become, I can say a house wife or you become submissive to your husband. And you become a wife. You leave all the bad stuff and you become, take the good stuff and you become…a woman (Female, age 21, urban, Free State). • The sentiments expressed above appear to be in line with the role society expects a woman to play, being a wife and looking after her family. • When a woman fails to reach this goal this attracts reprisals and name calling ‘lefetwa’ (spinster) from sectors of the community.

10. Defining role & expectations • There was dissent from respondents who did not think that this is what women should aspire to, as there are clear disadvantages to being married which cannot be ignored. • If a woman does not get married …she might be single, not married and called belittling names but have enough capacity to build a house for her parents. The community will look at her works and praise her works as good example to others. This will make the woman feel appreciated. Others might call her those belittling names but her works will speak louder in the community. (Female, age 36, urban, Free State). • Still on a positive note, women are also seen as generally astute and adept at finding solutions, both within and outside the immediate environment. • Even if there is a child being abused in the house, let me say in my house there is a child being abused, the first person who will see that the child has a problem, is the female teacher at school (Female, age 36, urban, Free State). • For example, you can find that next door the woman has certain problems, she will be the one who goes to consult with the social worker and look for help outside (Female, age 24, peri-urban, Free State).

11. Defining role & expectations • A further positive element noted is that what roles were traditionally ascribed to men are now being attributed to women - spontaneously describing them as ‘bread winners’ and ‘go getters’ who take full charge of their lives. They were described as hard-working, ambitious, independent, proactive and successful. • Women in Umlazi are hard workers, they do all they can to be financially independent. Gone are the days where women feel that a man has to earn more than me. These days sisters are doing it for themselves, from a young age... Uhm...you get women who are in charge in construction companies with big tenders and being independent, helpful to others… they like creating opportunities for others also. …Even if you can see the cars they drive, yoooh, men do not even come close to what women are driving. If you see a Lamborghini here, it’s being driven by a woman. It’s a good feeling as it encourages us too, to want to get there (Female, age 34, urban, KwaZulu-Natal). • Women’s groups are also seen as powerful vehicles for change in communities (e.g., stokvels, caregiver groups). • I think in the community as women, most things begin with the mother figure. Something like social clubs, women are the ones who always begin such things. Men always get advice from their women. Even if men can initiate such a thing but women will always be at the forefront (Female, age 34, peri-urban, Free State).

12. Women’s sexuality: expectations & decision making • Evidence of traditional notions of when women are expected to have sex e.g., sex after marriage; sex when out of school also emerged. On probing however, it was clear that this contradicts reality. (girls as young as 11 and 12 are engaging in sex and are mothers). • Now lately in our communities, parents have accepted that kids are having sex. They see with teenage pregnancy, a twelve year old would fall pregnant these days. Parents know that their kids are having sex with boys. There is no specific age to break virginity. Kids are having sex unexpectedly (Female, age 25, urban, KwaZulu-Natal). • …now it is not frowned upon like before, but when 11, 12 and 13 year olds started having children it was a huge scandal, but now it has been normalised, they are not chased away from home. It is now common. Parents now seek comfort in knowing the boy responsible for the pregnancy. Because of the danger posed by abortion, parents opt to allow them to have the baby, then that is fine (Female, 39, rural, KZN). • But nowadays a girl will pretend to be a virgin to the husband’s family, yet she and her husband know that they have been practicing sex long before marriage (laughter)…(Female, age 36, urban, Free State).

13. Motherhood: expectations & decision making • Having a child is seen as very important across all sites. • …when you are a woman, you have to have children. When you are without any children, you question that maybe something did not go right. Why does she not have children when she is a woman? You ask yourself such things. Maybe she is not a woman, she is something else (Female, age 36, urban, Free State). • Generally, if you are a woman you have to prove your fertility, with children seen as vital in carrying the family name forward. • Interviewer: So it’s very important to have a baby here. How old must you be, when is the age when they start to insult you? • F3: At age 23, 24. It doesn't matter even if you are working or you are not working, how you are going to support your child, it doesn't matter, married or not married. • The pressure doubles when a woman is married. • Even the in-laws, what they want from you is children. They want to see offspring from the family and if no offspring are produced they will start saying to their son- even if they liked you before, they start saying what are you doing with this person who doesn’t have children- we want children. They actually encourage the man to go and have other partners (Female, age 22, peri-urban, Free State).

14. Motherhood: expectations & decision making • Differences were seen in decisions to have children: • Generally, older, mature couples make joint decisions on number of children etc. • Some women report taking control of decisions on when and how many children they have e.g. starting contraception secretly, having hysterectomies etc. • When I delivered my girl and the doctor told me I had a baby girl, I told him to sew me up (sterilisation). …I signed the form in theatre that I want to stop having children. I did not discuss it with my husband; I took the decision for myself as I had got the baby girl I had been wanting all along (Female, 39, rural, KZN). • Younger women appear to make these decisions themselves, and largely appear to be ruled by emotions. • I think basically – when you are young and you are in this phase of ‘first love’, you don’t think outside of the relationship. You don’t think about effects of how having a baby will affect your lives at that moment; it’s a case of being in love and living just for that. I know this person and we are so much in love and the only thing to complete this perfect picture is a child, that’s the only thing I can say. (Female, age 25, urban, KwaZulu-Natal).

15. Sex & sexuality: • Generally, parents do not talk directly to their children about sex apart from discussions about safer sex and HIV. Most parents respond to the situation by taking young girls to the clinic for contraception as soon as they have their first period. • To add on what she said, when the mother sees that the daughter has started menstruation she will take her to the clinic (Female, age 31, urban, Free State). • HIV is an issue that has forced most parents to talk about issues to do with sexuality, with messages mostly focusing on HIV prevention. • Talking openly to partners about sexuality is approached differently – some feel that a certain degree of trust has to exist in the relationship for such open talk to be possible. • It depends on how comfortable you feel about the person. If I am not close enough with my boyfriend, you know I won’t be open to him. I would rather go and discuss with some of my friends. But if it is a person I feel comfortable with and open to, I can talk to him about it (Females, ages 21, 22, peri-urban, Free State). • Women in abusive relationships, are regarded as less able to communicate to their partners.

16. Women’s sexuality & decision making: e.g. Contraceptives • Common: pill, injection, condoms, morning after pill. • Less common: thigh sex, abstinence, virginity testing (KZN); withdrawal method, female condom. • Other practices: • various stuff taken post sex to prevent pregnancy (e.g. bicarbonate of soda, essence of life); • insert a sponge to absorb sperm; • muthi buried in the yard; • coloured string around the waist; • taking a shower; • cough or jump up and down to expel sperm; • abortion.

17. Women’s sexuality & decision making: e.g. contraceptives • A number of beliefs shared across sites regarding the use of contraceptives centred on the side effects of female contraceptives, especially the injectable, and included: • Changes in body shape; • Changes in weight • Changes in menstrual cycle (prolonged, irregular or absent menstruation) • Contraceptives cause infertility or permanent damage • Female contraceptives have side effects on males e.g. hip pain. • Views by men on contraceptives differ: while in one province men view this as responsible behaviour, misconceptions about contraceptive are rife. • A male participant described how his girlfriend, who was still at school, fell pregnant and that she was forced to have an abortion by her mother and then placed on contraceptives. The participant spoke about his anxiety in relation to his girlfriend being on contraceptives: • M6: My girlfriend was in high school and she fell pregnant, her mom made her have an abortion and then she put her on contraceptives. I wasn’t keen on that… like I didn't like the idea, she was too young... I thought at some point it would cause permanent infertility but she was like it was a safer option, she’d better on contraception just so we don’t make the same mistake twice…

18. SRH issues: beliefs & practices • At some sites, males and female participants also reported that men believe that women on injectable contraceptives “feel like jelly” or have increased vaginal fluids that made sexual intercourse less pleasurable. • *F3: It is because some of them say to their wives’ ‘oh now you are on prevention and your vagina becomes too wet’. When you prevent, they say the vagina does not feel like a woman’s, it becomes wet and moist. • F: Yes, sometimes you find that men believe that if you are on the injection, you become wet and have excessive vaginal fluids and they say sex is less pleasurable (females, age 20-40, peri-urban, Free State). • There were practices described at some of the sites which lead to the non-use of contraceptives and other health risks e.g. among the rural KwaZulu-Natal focus group participants, the use of various substances to facilitate ‘dry sex’ or as aphrodisiacs, such as ‘kuber’ or ‘snuff’ was usually not accompanied by the use of contraceptives or condoms.

19. SRH issues: beliefs & practices • Beliefs about being a ‘hot’ or a ‘cold’ woman contributed to women following practices to facilitate dry sex and ‘hot’ sex – which resulted in the non-use of contraceptives, and of condoms. • F2: What I would like to know now is, when using all these aphrodisiacs is a condom still used? • F7: No, how are you going to transfer the heat if you are wearing a condom. • F1: For him to feel the heat, there has to be direct contact...I don’t think after using all those things to enhance and you use a condom...that would be spoiling it then (females, 20-40 years, rural, KwaZulu-Natal).

20. So what are the SRH priorities?

21. How women are defined, and in turn define themselves may place pressure on them to conform, placing them at risk. • Risks for women are heightened by practices that conform to cultural notions of who they are. • Cultural notions still enshrine definitions of women and role expectations, but there appears to be a shift towards women finding their own identity. • This needs to be encouraged through messaging and shaped through information and women-targeted interventions. • A lot of misinformation around sexuality, contraceptives, and condoms still exists. Women and men do not have enough knowledge about contraceptives, condoms, TOP etc. to be able to make informed decisions. • This lack of information results in a number of detrimental practices that could be avoided, e.g. 1) Men who know women are on contraceptives do not use condoms – increasing risk of HIV and STIs. 2) The use of agents to facilitate dry sex. 3) Use of “Dr Love’s” – illegitimate doctors who perform backstreet abortions. • Need for interventions to have this understanding & target these beliefs and practices. Conclusions:

22. Sexual and Reproductive Health must be addressed for women and girls. • There is a need for widespread information on the side effects of contraceptives, in particular, injectable contraceptives to address myths. • The availability & strategic marketing of female-friendly strategies is essential if women are to take charge of their health and their lives. • Promotion of contraceptive & other SRH rights for women and girls matched with training of health care workers to provide these services in non-judgmental ways. • Promotion of the right to access TOP matched with training of health care staff to provide these services. • Need for widespread information on the effects of backstreet abortions, use of drying agents, effects of muthi etc. • A number of service provision issues need to be addressed, e.g. hospitals that turn women away for TOP etc. • A vital part of any process of understanding is to step back and see the broader picture with the aim of creating a health system that works for everyone. • It is important to identify knowledge gaps and provide relevant health information. • Target communities to ensure they are well informed even before they need to access services. Recommendations for service provision: