Gender Inequality and Reproductive Health
In several regions of the world, the age of marriage is increasing, the age of sexual maturity is decreasing(36) and “sexual debut” is occurring earlier in young people’s lives, lengthening the time when women and men face risks to their health.
In most settings, gender norms shape young women’s and men’s early sexual experiences. Young women are often pressured or coerced to accept risky sexual behaviour, while young men are encouraged to take sexual risks—and may well expect their partners to comply or face intimidation or violence. Early sexual experience is often associated with other risky behaviours like alcohol and drug use or smoking, particularly for boys.
Many girls’ first sexual experiences involve coercion.(37) The younger the girl and the greater the age difference between her and the male, the greater the likelihood of an exploitive relationship.
Unequal gender norms persist in many parts of the world, with young men often encouraged to enlarge their sexual experiences while restraint is urged on young women. In some settings, the balance may be highly skewed, with very high demands for women to remain chaste coupled with few demands (if any) on men to practise sexual self-control or to treat partners with respect. For young men and women, these different expectations are harmful and have a negative impact on the establishment of healthy, responsible and equitable relationships.
Studies in 21 countries indicate that more than one third of boys’ first sexual experience is with a sex worker. Sexually active boys report having sexual relations with a variety of partners, including girlfriends, informal female acquaintances and sex workers.(38)
Young women generally engage in sexual relations within the context of a relationship, and see it as a means of strengthening the relationship. Low power, fear of violence, and a sense of “marital duty” prevent many women from discussing the timing of their sexual relations with their husbands.
Unequal gender norms, including expectations of female passivity, often reduce young women’s ability to make informed choices about their sexual health. Fear of losing one’s partner can also limit their choices. Studies in the United States suggest that among girls abandoned after sexual initiation, the resulting depression is as intense as that which follows the death of a family member.(39)
Male sexual behaviour reflects and affirms masculine identity in all cultures. But cultural concepts of identity vary. Changing social and cultural conditions (e.g., more education, the changing nature of work, access to mass media, women’s empowerment, generational value shifts, increases in informal unions, decreased roles for extended family, increased costs of child-raising, urbanization and international migration) are redefining accepted concepts of masculinity and male-female relationships, with an increased focus on responsibility.
group research in South Africa found that gender norms limit young
women’s negotiating power to protect themselves in sexual encounters.
“Dominant social norms of masculinity portrayed young men as conquering
heroes and macho risk-takers in the sexual arena,” while young women were predisposed
“to use the responses of passivity or fruitless resistance in the face of male
Girls tend to say the reason they engage in sexual activity is to cement a
relationship with someone they love. If they insist on condom use, it may jeopardize
that relationship. Young men may capitalize on this emotion when seeking to
engage in sex with young women.
In Senegal, young people aged 14-16 in
focus groups agreed that a lack of respect characterizes expectations of relationships.
Boys suspected girls of being primarily interested in money and other material
things, while both stated that girls who refuse to have sex face the possibility of
beatings or rape.
Rio de Janeiro’s Instituto Promundo
researched what makes some young men behave more positively towards women
than others. The “gender-equitable” men sought relationships based on equality and
intimacy rather than sexual conquest, opposed violence against women, wanted
to share responsibility in caring for their children and wanted to have some responsibility
for reproductive health. This research gave rise to a programme promoting
a healthy masculinity among adolescent boys through activities to raise
awareness around violence against women and promote good health.See Sources
DATING AND RELATIONSHIPS Patterns of relationships between young men and young women are changing.(40) Rising age at marriage increases the opportunity for friendships, dating and more serious partnerships between young males and females. Its prevalence varies in different settings and social contexts.
In some settings, dating is common, if irregular, among large proportions of youth, but the relationship contents vary. The intensity of relationships varies with age: college students more commonly form close attachments. For the great majority of youth (particularly in Eastern and Western Asia) these do not include sexual relations.
Parental oversight of adolescent relationships is common, but large minorities—larger for males than females—form attachments without permission. Recent research in the United States(41) indicates that at least a fifth of young adolescents are engaging in sexual relationships, often without parental knowledge. Adult knowledge of their children’s sexual experience is often limited.
In settings where values insist on premarital abstinence, there is a greater tendency to withhold information about sexual and reproductive health from youth and from policy discussion.
EARLIER ONSET OF SEXUAL ACTIVITY Sexual initiation is increasingly occurring outside of marriage, particularly for boys. Both adolescent boys and girls who engage in sexual activity often begin with little knowledge of sexuality, reproductive health, safer sexual practices, or their right to refuse and to abstain.
In Peru, the Philippines, Thailand and Viet Nam, both young men and young women are more likely to consider premarital sex to be more acceptable for males than for females.(42) Young men tend to begin having sex at least two to three years before young women—in some parts of the world within the context of sexual initiation rites or with a sex worker.(43)
In Brazil, Ethiopia, Gabon, Haiti, Kenya, Latvia, Malawi, Nicaragua and Poland, more than one quarter of young men aged 15-19 interviewed said they first had sex before age 15.(44) In Latin America and the Caribbean, the average age at first sexual encounter is earlier for males than females, ranging from 12.7 years for boys and 15.6 for girls in Jamaica to 16.0 for boys and 17.9 for girls in Chile.(45)
One in-depth study uncovered two patterns of young men’s first sexual experiences—findings that parallel other research.(46) The first pattern, termed “impulsive”, took place at an early age (15 or younger), motivated by curiosity, reported “physical need” or peer pressure. It usually occurred in a hotel or brothel with a sex worker. Condoms were used, if any contraception was. In the second pattern, “occasional”, young men’s first sexual experience took place with a friend or casual acquaintance in varied locations, often spontaneously and without contraception.
Premarital sexual activity for adolescent girls varies considerably in different regions: less than 12 per cent in Asia, up to a quarter in Latin America and around half in sub-Saharan Africa.
In sub-Saharan Africa in particular, girls’ early sexual relationships are very likely to occur with men who are considerably older, often in exchange for money or gifts. These conditions significantly reduce girls’ ability to negotiate safer sex and increase their chances of contracting STIs and HIV or becoming pregnant. Because cross-generational sex is driven in part by poverty, and is also seen as a way to increase one’s status, parents sometimes encourage it.(47)
As couples move towards marriage, premarital sex may well occur in a majority of relationships, even in relatively conservative settings.(48)
A lack of other opportunities such as employment, sports, or religious and cultural activities tends to increase the centrality of sexual behaviour in adolescents’ self-definition and self-esteem.
UNWANTED PREGNANCY Many young men and women are beginning sexual activity earlier in life. By not choosing abstinence as an option, a larger proportion of adolescents and young people need access to family planning methods to avoid unwanted pregnancies.(49)
Due to limited knowledge and guidance, adolescents are less likely to practise safer sex or to use contraception. Contraceptive use is still infrequent in most early sexual experiences. Young women consistently report lower usage rates than men, evidence of their unequal power in negotiating use of family planning with their partner or restrictions on their access to services (due to lack of information, shame, laws, health provider attitudes and practices or social mores).
Community studies suggest that between 10 and 40 per cent of young, unmarried women have experienced unwanted pregnancy. At the high end, in studies of soon-to-be married women, unmarried factory workers, out-of-school adolescents and women seeking health care, more than one third had an unwanted pregnancy.(50)
A majority of unwanted pregnancies among young, unmarried women end in abortion,(51) posing a serious public health concern since many—if not most—of these abortions are unsafe, carried out by people lacking formal medical training and in facilities with substandard hygiene and care.
Studies in four Latin American countries found that between 10 and 14 per cent of pregnancies among young, never-married women ended in abortion; four other countries show levels half as high. The pattern in Asia is diverse in the few countries where studies have been undertaken.(52) In Kazakhstan, where recourse to abortion for unwanted pregnancy has been accepted historically, rates remain high, about 45 per cent; by contrast, in the Philippines, it is relatively rare (about 7 per cent) and births after marriage predominate.(53)
CONTRACEPTIVE USE Detailed data on premarital sexual behaviour have only recently been collected in developing countries. In 13 countries with appropriate surveys of the timing of different sexual and reproductive behaviours, large differentials are observed in the age of sexual debut and in the proportion of sexual activity protected by contraception.(54)
Women from the three Asian countries studied(55) were highly likely to remain virgins until marriage (above 95 per cent in two of the countries), but once sexually active they were less likely to be protected by contraceptive use. Premarital virginity rates in Latin America(56) varied from 58 per cent (Colombia) to 90 per cent (Nicaragua), and in Africa from 45 per cent (Kenya) to 73 per cent (Zimbabwe).
In the Latin American and African countries studied, more than 40 per cent of pregnancies to sexually active unmarried women resulted in live births prior to marriage. Live births shortly after marriage were common in all regions. In only two Latin American countries (Brazil and Colombia) was more than half of the sexual activity between sexual initiation and marriage protected by contraception. Most commonly, two thirds to three quarters of sexual activity was unprotected.
As young couples establish long-term relationships, they are more likely to practise contraception, but tend to use methods other than condoms—hampering their ability to protect themselves from sexually transmitted infections, including HIV.(57)