HIV, SEX AND POVERTY IN SUB­SAHARAN AFRICA: WHY THE 

CONDOM DOESN’T PROTECT WOMEN FROM THE AIDS VIRUS 
 
 
 
Lisa
Nicol
Woods











Dissertation
Supervisor



Dr.
Edward
Simpson







Medical
Anthropology








This
dissertation
is
submitted
in
partial
fulfilment
of
the
requirements
for
the

degree
of
MA
Medical
Anthropology
of
the
School
of
Oriental
and
African
Studies

(University
of
London)





15
September
2009



10,000
words







Declaration 
I
have
read
and
understood
regulation
17.9
(Regulations
for
Students
of
SOAS)

concerning
plagiarism.

I
undertake
that
all
material
presented
for
examination
is

my
own
work
and
has
not
been
written
for
me,
in
whole
or
in
part,
by
any
other

person(s).

I
also
undertake
that
any
quotation
or
paraphrase
from
the
published

or
unpublished
work
of
another
person
has
been
duly
acknowledged
in
the
work

which
I
present
for
examination.

I
give
permission
for
a
copy
of
my
dissertation

to
be
held
at
the
School’s
discretion,
following
final
examination,
to
be
made

available
for
reference.



Name:
Lisa
Nicol
Woods






Signature:  


 1

HIV, SEX AND POVERTY IN SUB­SAHARAN AFRICA: WHY THE 
CONDOM DOESN’T PROTECT WOMEN FROM THE AIDS VIRUS 


 
 
 
 
 
 


Either
people’s
beliefs
about
condoms,
fertility
and
disease
prevent
them
from

practicing
safe
sex
or
they
are
constrained
by
the
larger
social
conditions
in
their

lives
such
as
poverty
and
unemployment
that
result
in
kind
of
resignation,
a
feeling

that
HIV
is
inevitable,
and
beyond
one’s
power
to
prevent
–
Helen
Esptein

(2001:20).1











For
women
most
at
risk
of
HIV
infection,
life
choices
are
limited
by
racism,
sexism,

political
violence
and
grinding
poverty
–
Paul
Farmer
(1996:33)











Men
are
the
solution
to
HIV
prevention
–
Christine
Obbo
(1993)2







Abstract: 
Do
condoms
exacerbate
HIV/AIDS
in
Sub‐Saharan
Africa,
or
has
the
scientific

community
been
drawn
into
yet
another
row
with
the
Vatican
on
the
legitimacy

of
condoms?
This
paper
is
in
response
to
Pope
Benedict
XVI’s
assertion
that
“You

can’t
resolve
it
[HIV]
with
the
distribution
of
condoms.”
It
juxtaposes
the

cacophony
of
discourses
–
religious,
moralist,
scientific,
and
anthropological
–

against
ethnographic
and
statistical
trends
that
show
in
spite
of
condom
social

marketing,
the
condom
faces
an
uphill
battle
to
social
acceptance.
The
paper

looks
at
the
reliance
of
the
biomedical
community
on
the
condom
and
offers
that

the
co‐factors
of
infection,
such
as
poverty
and
gender
inequality
are
no
match

for
the
condom,
and
must
be
factored
into
a
de‐medicalized
approach
of
HIV

prevention.
Condom
promotion
is
not
completely
ruled
out,
rather

anthropologists
are
challenged
to
partner
with
biomedical
researchers
to
include

the
co‐factors
of
HIV
infection
such
as
poverty
and
gender
inequality,
on

HIV/AIDS
prevention
research
agendas,
if
Africa
is
to
ever
witness
a
true

decrease
in
HIV
prevalence
rates,
rather
than
stabilization
attributed
to
“die‐off.”





 2

 
 

TABLE OF CONTENTS 

INTRODUCTION  4 

CHAPTER 1  THE DISHARMONIOUS DISCOURSES ON AIDS IN AFRICA  8 
ANTHROPOLOGICAL CONTRIBUTIONS TO AIDS RESEARCH IN AFRICA  8 
ANTHROPOLOGISTS AS HANDMAIDENS  8 
ANTHROPOLOGISTS AS CULTURAL EXPERTS: THE COMMUNITY PARADIGM  9 
ANTHROPOLOGISTS AS POLITICAL ECONOMISTS: THE STRUCTURAL VIOLENCE PARADIGM  10 
THE FUTURE: AN ANTHROPOLOGICAL SYNTHESIS  10 
AIDS, CONDOMS AND THE BIOPOLITICAL  11 
FROM GLOBAL TO LOCAL: RELIGION’S INFLUENCE ON CONDOM PROMOTION AND USE  13 
A MINI‐ANTHROPOLOGY OF CONDOM PROMOTION IN AFRICA  15 

CHAPTER 2  FEMALE BODIES, MALE CONTROL  19 
THE PERFORMANCE OF TRUST  20 
THE RISKY SEX OF MARRIED COUPLES  21 
THE SYMBOLIC AND MATERIAL VALUE OF FERTILITY  23 

CHAPTER 3  THE SOCIAL AND COSMOLOGICAL DIMENSIONS OF SEX  25 
REPRESENTATIONS OF SEMEN  25 
CONDOMS AND GOOD SEX DON’T MIX  26 

CHAPTER 4  THE SOCIAL PRODUCTION OF AIDS  28 
THE SEXUAL CONSEQUENCES OF POVERTY  28 
MASCULINITY, MIGRATION, AND SEXUAL RISK TAKING  29 

CONCLUSION  31 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


 3

 INTRODUCTION 
 
The
crux
of
HIV
preventiona
lies
in
the
epidemiologically
sound
risk
reduction

strategy
known
as
the
ABC
approach.
For
the
Joint
United
Nations
Programme

on
HIV/AIDS
(UNAIDS),
ABC
means:
Abstinence
or
delaying
first
sex;
being
safer

by
being
faithful
to
one
partner
or
by
reducing
the
number
of
sexual
partners;

and
correct
and
consistent
use
of
condoms
for
sexually
active
young
people,

couples
in
which
one
partner
is
HIV‐positive,
sex
workers
and
their
clients,
and

anyone
engaging
in
sexual
activity
with
partners
who
may
have
been
at
risk
of

HIV
exposure
(UNAIDS,
2004:6).3
The
condom
remains
the
cornerstone
of
HIV

prevention
and
is
the
most
controversial
component
of
ABC.
Religious

organizations
and
traditionalists
oppose
the
condom
on
grounds
that
it
leads
to

sexually
immoral
behavior;
but
biomedicine
hails
the
condom
as
the
single
most

effective
technology
to
prevent
the
transmission
of
HIV.b




The
social
marketing
of
condoms
remains
at
the
forefront
of
AIDS
prevention
in

Africa
but
the
condomc
has
failed
to
reduce
prevalence
rates
in
general,
amongst

women
in
particular.
In
fact,
UNAIDS
now
reports
that
AIDS
–
an
illness
once

associated
with
male
homosexuals
and
injecting
drug
users
in
America
–
has
a

woman’s
face.
Recent
statistics
show
that
women
comprise
nearly
50
percent
of

all
people
infected
with
HIV
worldwide,
and
60
percent
of
people
living
with

HIV/AIDS
in
Sub‐Saharan
African
(UNAIDS,
2008:33).4
The
feminization
of
AIDS

poses
a
challenge
for
the
ABC
approach
to
HIV
prevention.
“For
women
and
girls

who
are
sexually
assaulted,
in
abusive
relationships,
or
see
sex
as
the
only
means

of
survival,
abstinence
is
not
a
realistic
option;
monogamy
only
works
if
both

partners
play
by
the
same
rules;
and
condom
use
is
almost
invariably
a
male

decision”
(Wintersgill,
2004:1).



Opponents
of
disease‐specific
health
interventions
claim
that
the
intense
focus

on
AIDS
prevention
distorts
international
health
aid,
and
steals
valuable

resources
needed
to
boost
overall
health
systems
(England
cited
in
Morris,

2008).5
I
argue
that
the
syndrome
has
earned
the
attention
it
receives
in
Africa

because
the
continent
bears
a
disproportionate
amount
of
disease
and
death

associated
with
the
syndrome,
and
it
is
the
leading
killer
of
women.
For
example,

in
2007
an
estimated
1.9
million
people
were
infected
with
HIV
in
Sub‐Saharan

Africa,
bringing
the
known
number
of
people
living
with
HIV
to
22
million.
About

67
percent
of
the
32.9
million
people
living
with
HIV
reside
in
this
region;
and
75

percent
of
all
AIDS
deaths
in
2007
occurred
there
(UNAIDS,
2008).6
The
United

Nations
Children’s
Fund
reports
that
an
estimated
12
million
children
from
0
to

17‐years
old
have
become
single
or
double
orphansd
because
of
AIDS;

subsequently,
the
region
is
home
to
80
percent
of
the
developing
world’s

children
who
have
lost
a
parent
to
AIDS
(UNICEF,
2006).



























































a
The
human
immunodeficiency
virus
is
the
lentivirus
that
causes
acquired
immunodeficiency


syndrome
(AIDS),

b
In
this
document
the
AIDS
virus
and
HIV
have
the
same
meaning,
and
HIV/AIDS
refers
to
the


discursive
field,
research
endeavours,
and
people
affected
by
or
living
with
the
illness.

c
This
dissertation
will
focus
on
the
male
condoms
because
the
female
condom
is
not
widely


available
in
sub‐Saharan
Africa
because
it
is
relatively
expensive
(UNAIDS,
2008).

d
Single
orphans
have
lost
a
mother
or
father;
double
orphans
have
lost
both
parents.




 4










Figure
1:
HIV
prevalence
(%)
amongst
adults,
15‐49
in
Africa
(2007)
(UNAIDS,
2008b:
39)7


These
worrying
trends
persist
regardless
of
an
increased
supply
and
demand
for

condoms
on
the
continent.
I
have
therefore
used
social
science
studies
and

ethnographic
accounts
from
countries
in
central
and
eastern
Africa
(the

Democratic
People’s
Republic
of
Congo,
Tanzania,
Uganda);
southern
Africa

(Malawi,
South
Africa,
Zambia,
Zimbabwe),
and
Western
Africa
(Nigeria)
–
all
in

the
Sub‐Saharan
African
region.
Although
impossible
to
construct
a
single,

unifying
cultural
perspective
from
such
incongruent
ethnicities
and
countries,

salient
themes
appear:
condoms
are
associated
with
promiscuity
and
reduced

fertility,
women
depend
on
men
to
use
condoms,
condoms
interrupt
the
pleasure

and
meaning
of
sex,
and
condom
use
is
a
controversial
topic
amongst
regular

partners.



First,
let
me
state
that
I
am
by
no
means
anti‐condom!
On
the
contrary,
I
believe

that
every
human
should
have
the
freedom
to
make
choices
in
regards
to
his
or

her
sexuality
–
without
interference
from
the
Church
or
State.
While
I
disagree

with
the
Vatican’s
distortion
of
scientific
data
to
further
its
theological
agenda,
I

cannot
ignore
ethnographic
trends,
which
illustrate
that
the
introduction
of

condoms
into
stable
heterosexual
unions
represents
an
unacceptable
risk
to

many
sub‐Saharan
African
women
in
particular.
I
cannot
silence
anthropological

studies,
which
underscore
a
wide
range
of
cultural
attitudes
toward
sex
and

procreation,
which
make
condom
use
socially
unacceptable.
In
this
paper
will

examine
the
following:



In
Chapter
1,
I
rely
on
the
Foucauldian
concept
of
the
discourse
as
the
thing
that

“creates
the
effects
of
truth”
or
decides
what
is
“in
the
true.”
I
apply
the
notion
of

discourse
in
my
analysis
of
the
religious,
moralist,
and
biomedical
trends,
which

dictate
HIV/AIDS
research
and
condom
promotion
in
Sub‐Saharan
Africa.
I
trace

the
role
of
anthropological
contributions
to
sex
and
AIDS
research
in
Africa
from

that
of
the
“handmaiden”
who
delivered
“exotic”
cultural
practices
to
support
the



 5

biomedical
fascination
with
the
epidemiological
patterns
of
HIV/AIDS,
to
that
of

the
“cultural
expert”
and
“political
economist”
who
oppose
the
medicalization
of

HIV
prevention,
and
look
to
socio‐cultural
and
economic
forces
which
conspire

to
socially
produce
AIDS.
This
chapter
also
examines
the
effects
of
the
Vatican

and
local
churches
in
opposing
condom
use,
the
raging
debate
between
religion

and
science
on
the
appropriateness
of
the
condom
to
reduce
the
threat
of

HIV/AIDS,
and
ethnographic
accounts
which
manifest
the
dynamics
of
this

debate.
I
conclude
with
an
ethno‐history
of
condom
marketing
in
sub‐Saharan

Africa
and
calls
for
an
improved
evidence
base
for
condom
promotion,
and
the

expansion
of
HIV
prevention
to
include
non‐biomedical
factors
of
infection.




Chapter
2
looks
at
the
value
of
condoms
in
relation
to
women’s
ability
to

negotiate
condom
use
with
regular
sexual
partners.
I
posit
that
the
condom
is

impotent
to
protect
vulnerable
women
from
HIV
infection
because
of
pervasive

gender
inequality.
My
definition
of
gender
inequality
is
based
on
access
to
cash,

credit,
land,
political
participation,
and
the
implicit
social
acceptance
that
a

woman’s
bodily
integrity
is
not
as
important
as
her
husband’s
conjugal
rights.

The
symbolic
and
material
value
of
fertility
is
also
examined
in
relation
to

women
and
men’s
acceptance
of
condoms
and
the
implications
this
holds
for

condom
promotion.
Finally,
I
tackle
the
issue
of
risk
and
trust
in
relation
to

condom
use
in
stable
unions.
I
use
ethnographic
analyses
from
Tanzania
and

Malawi
to
illustrate
how
condom
use
amongst
married
couples
can
constitute
an

immediate
risk
greater
than
that
posed
by
a
dimly
understood
virus.



In
Chapter
3,
I
examine
the
fate
of
the
condom
in
cultural
contexts
where
bodily

fluids
have
cosmological
and
social
dimensions.
I
juxtapose
western
biomedical

definitions
of
procreation
and
good
sex
with
ethnographic
accounts
from
Zambia

and
Tanzania
to
illustrate
how
condoms
can
oppose
the
cultural
meanings
of
sex

and
faces
opposition
as
the
cornerstone
of
HIV
prevention.

In
the
studies

anthropologists
recommend
a
multi‐faceted
approach
to
HIV
prevention,
while

urging
condom
programmers
to
use
ethnographic
data
to
implement
more

culturally
appropriate
interventions.



In
Chapter
4,
I
adopt
the
paradigm
of
the
political
economist
anthropologist
and

examine
how
structural
and
economic
forces
such
as
structural
adjustment

programmes
(SAPs)
and
persistent
poverty
lead
to
an
environment
that

necessitates,
even
expects,
women
to
trade
sexual
favours
for
subsistence.
I
will

also
explore
the
role
that
urban‐rural
migration
plays
in
men’s
risk
to
HIV

infection,
and
the
construction
of
masculinities
and
sexual‐risk
taking
of
men

working
in
the
South
African
gold
mines.
The
overarching
theme
of
this
chapter

is
that
the
socio‐economic
dynamics
in
which
sexual
relations
occur
often
escape

health
belief
models
and
biomedical
assumptions,
which
posit
that
awareness
of

HIV
infection
and
access
to
condoms,
will
lead
to
their
use.

 
In
conclusion,
I
throw
down
the
gauntlet
to
medical
anthropologists
to

spearhead
efforts
to
de‐medicalize
HIV
prevention,
and
to
revisit
the
fieldwork

tradition
to
ensure
that
the
lebenswelt
of
people
affected
by
HIV/AIDS
are

accurately
depicted.
Medical
anthropologists
are
also
challenged
to
advocate

international
organizations
for
the
inclusion
of
the
co‐factors
of
HIV



 6

transmission
–
poverty
and
gender
inequality
–
into
HIV
prevention
efforts,
and

to
collaborate
with
traditional
healers
to
craft
the
appropriate
local
responses
to

the
AIDS
epidemic.



 7





CHAPTER 1 
 
THE DISHARMONIOUS DISCOURSES ON AIDS IN AFRICA 


Anthropological Contributions to AIDS Research in Africa 
Since
the
emergence
of
the
AIDS
epidemic
in
the
1980s
there
has
been
a

disparate
anthropological
approach
to
the
understanding
of
its
epidemiological

patterns
and
the
socio‐cultural
factors
driving
the
epidemic.
Leading
medical

anthropologists
have
critiqued
the
discipline’s
past
involvement,
and
are
calling

for
a
return
to
the
basic
anthropological
principles
of
doing
no
harm
and

ensuring
that
the
lebenswelt
of
people
affected
by
HIV/AIDS
are
accurately

portrayed
in
ethnographic
analyses
and
joint
social
science
research
endeavours.

I
will
rely
on
the
stylised
representations
of
anthropological
involvement
in
AIDS

research
in
Africa,
which
include
(Farmer,
1998):8



1. Anthropologists
as
Handmaidens:
The
Biomedical
Paradigm;

2. Anthropologists
as
Cultural
Experts:
The
Community
Paradigm;

3. Anthropologists
as
Political
Economists:
The
Structural
Violence

Paradigm;
and


4. The
Future:
An
Anthropological
Synthesis.



Anthropologists
as
Handmaidens

Colonial
administrators,
missionaries,
adventurers
and
armchair
anthropologists

studied
African
sexuality
as
part
of
a
“morbid
curiosity”
into
the
exotic
lives
of

the
“natives”
(Gausset,
510:2001).9
During
this
period
of
fascination
with
the

“exoticism”
of
the
Other,
anthropology
suffered
a
“crisis
in
representation”–
a

moment
of
self‐reflexivity
that
threatened
to
paralyse
the
discipline
after

decades
of
allying
with
colonial
administrations,
and
other
unfortunate
missteps

such
as
ethnocentrism
and
ethical
issues
regarding
the
American‐Vietnamese

war.
The
question
of
whether
anthropology
was
the
“bastard
of
colonialism”
or

“the
legitimate
child
of
the
Enlightenment”
coincided
with
the
cessation
of
sexual

research
on
the
continent.
But
AIDS
made
it
legitimate
to
study
sexuality
in

Africa
again,
and
at
the
behest
of
biomedical
researchers,
anthropologists
were

asked
to
problematise
the
ratio
of
male
to
female
cases
of
AIDS.
In
Africa,
the

prevalence
ratio
stood
at
1:1
while
in
the
northe
the
ratio
was
13:1
(Packard
and

Epstein,
1991).

Anthropologists
were
commissioned
to
analyse
ethnographic

records
and
conduct
fieldwork
to
solve
the
following
epidemiological
riddles:



1. Why
is
HIV
in
Africa
transmitted
differently
from
the
west?

2. Why
are
as
many
African
women
as
men
infected
with
HIV?

3. Why
does
African
sexuality
result
in
heterosexual
infection?



Since
biomedical
researchers
had
already
constructed
a
line
of
inquiry
that

excluded
any
other
possibilities
for
the
varied
patterns
of
HIV
transmission,


























































e
In
this
paper,
“north”
refers
to
North
America
and
Western
Europe.



 8

anthropologists
focussed
on
the
differences
of
the
African,
the
quintessential

other,
and
relegated
other
possibilities
to
the
margins.
“Like
the
first
studies
of

African
sexuality,
it
was
once
again
the
‘exotic,
traditional,
irrational
and

immoral
practices’
that
were
the
focus
of
the
research.
If
the
pattern
of
AIDS

epidemics
was
different
in
Africa
than
in
Europe,
the
explanation
obviously
had

to
be
the
difference
between
African
and
European
culture
and
sexualities.
Some

used
the
‘Human
Relation
Files
Area’
in
order
to
find
significant
relations,
or
to

try
to
establish
an
ethnic
cartography
of
the
risk
of
infection
according
to
the

sexual
and
ritual
practices”
(Fassin
cited
in
Gausset,
2001:511).
This
“ethno‐
pornography”
revealed
scarification
rituals
performed
with
the
same
knife,
dry

sex,
widow
inheritance,
wife
sharing,
witchcraft
beliefs
(as
opposed
to
Koch’s

germ
theory)
the
rumoured
mixing
and
sharing
of
monkey’s
blood
in
“love

magic”
(Gausset,
2001).
This
ethnographic
“evidence”
was
presented
as

culturally‐specific
HIV‐related
“risk
behaviors.”
For
example,
in
the
Social
Factors

in
the
Transmission
of
Control
of
AIDS
in
Africa
(1987),
commissioned
by
the

United
States
Agency
for
International
Development
(USAID),
an
anthropologist

reported
the
following
of
the
Tonga
in
Zambia:




There
is
a
widespread
fear
of
impotence
[in
Africa].
Our
readings

mention
 instances
 where
 an
 older
 man
 might
 ask
 a
 younger
 man

to
 impregnate
 his
 wife.
 The
 Gwembe
 Tonga
 of
 Zambia
 use

euphemistic
invitation
in
these
circumstances
…
‘go
and
cut
wood

for
 me,
 my
 friend’
 …
 This
 illuminates
 our
 understanding
 of

perception
 of
 sexuality
 in
 certain
 traditional
 African
 settings
 but

also
 indicates
 another
 –
 though
 limited
 –
 instance
 of
 a
 possible

route
for
spreading
AIDS
through
increasing
the
number
of
sexual

partners
(Brokensha
cited
in
Packard
and
Epstein,
1991:775).10



While
there
is
no
argument
that
this
sexual
practice
is
a
pathway
for
HIV

infection,
this
construction
of
risk
fueled
the
notion
that
Africans
are
sexually

promiscuous,
and
diverted
the
focus
from
more
common
circumstances
in
which

HIV
is
transmitted.
In
other
cases,
anthropologist‐reported
sexual
practices
were

divorced
from
its
attendant
social
and
cultural
contexts,
and
excluded
the
more

common
but
less
exotic
causes
of
HIV
infection
such
as
malnutrition,
poverty,
ill

health,
and
over‐
and
under‐development
(Packard
and
Esptein,
1991).




Anthropologists
as
Cultural
Experts:
The
Community
Paradigm 
As
HIV
prevention
efforts
failed
to
have
its
desired
effect,
anthropologists

diverted
their
focus
from
individual
risk
behaviors.
“[I]t
had
become
clear
that
a

far
more
complex
set
of
social,
structural,
and
cultural
factors
mediate
the

structure
of
risk
in
every
population
group,
and
that
the
dynamics
of
individual

psychology
could
not
be
expected
to
fully
explain
changes
in
sexual
conduct

without
taking
these
broader
issues
into
account”
(Ramin,
2007:128).
As
such,

the
early
1990s
saw
anthropologists
as
cultural
experts,
promoting
the

understanding
of
culture
as
the
key
to
a
more
enlightened
AIDS
prevention

strategy.
For
example,
Lyons
(1997)
identified
disparate
attitudes
toward

condom
use
in
Uganda
which
ranged
from
“condoms
are
not
African,”
“condoms

will
promote
promiscuity
and
moral
lassitude,”
“condoms
are
a
ploy
to
control

our
population
size,”
“condoms
kill
women,”
and
“condoms
are
evil”
to
“condoms



 9

will
hinder
the
reconstruction
of
Uganda’”
(Lyons
cited
in
Ramin,
2007:130).


Such
anthropological
information
was
useful
in
designing
culturally
appropriate

condom
promotion
interventions
in
the
country.




Anthropologists
as
Political
Economists:
The
Structural
Violence
Paradigm

During
the
1990s
a
second
school
of
anthropological
thought
emerged
alongside

the
cultural
experts,
in
which
the
lack
of
condom
use
and
the
unchecked

transmission
of
the
AIDS
virus
was
attributed
to
poverty,
and
its
attendant

features.
Anthropologists
as
political
economists
posit
that
sexual
risk
taking
is

one
manifestation
of
material
desperation
and
structural
inequalities.11
“In

developing
these
concepts,
the
work
considers
the
interactive
or
synergistic

effects
of
social
factors
such
as
poverty
and
economic
exploitation,
gender

power,
sexual
oppression,
racism,
and
social
exclusion”
(Parker,
2001:169).





The
mid‐1990s
saw
a
proliferation
of
ethnographic
analyses
on
the
socio‐
cultural
and
political
structures
that
increase
vulnerability
to
AIDS
–
although

few
full
ethnographies
have
been
published
on
the
social
production
of
AIDS
and

AIDS
suffering.f

Paul
Farmer
(2005),
a
leading
medical
anthropologist
and

doctor,
showed
how
the
building
of
an
hydroelectric
dam
led
to
the

displacement,
loss
of
income,
and
forced
migration
of
rural
poor
Haitians
–

which
put
the
population
at
risk
to
AIDS
–
long
before
they
engaged
in
“risk

behaviors.”
Schoepf
(1992)
writes
on
how
the
financial
crisis
of
the
1980s
–
not

exotic
sexual
practices
–
forced
women
in
Sub‐Saharan
Africa
to
rely
on
sexual

survival
strategies
that
have
turned
into
“death
strategies.”
Porter
(1994)

investigated
how
young
Ghanaian
women
who
migrated
to
neighboring
Côte

d'Ivoire
found
upon
arrival
that
sex
work
was
the
only
livelihood
available;
many

returned
home
to
die
from
AIDS.
Anthropologists
as
political
economists
offered

that
condoms,
or
the
ABC
strategy
for
that
matter,
wouldn’t
mitigate
AIDS
risk,

rather
that
the
epidemic
can
only
be
addressed
when
the
economic
and
socio‐
cultural
structures,
which
constrain
people
from
making
optimal
health
choices,

or
“structural
violence”
is
challenged.


 
The
Future:
An
Anthropological
Synthesis

There
has
been
a
call
for
anthropologists
to
develop
a
better
working

relationship
with
medical
researchers
and
for
them
to
lead
the
résistance
to

scientific
endeavours,
which
suggest
racism,
sexism,
or
any
other
other
–ism
that

misinforms
HIV/AIDS
research
and
prevention.
“This
will
necessitate

adjustments
on
both
sides.
Social
scientists
need
to
resist
attempts
to
limit
their

input
to
collecting
and
presenting
cultural
artifacts
and
be
critical
of
those
who

continue
to
do
so...
[and
joint]
agendas
need
to
be
expanded
to
address
broader

issues
of
African
social
and
economic
life
and
not
simply
the
‘sexual
life
of
the

natives
and
other
forms
of
risk
behaviors”
(Packard
and
Epstein,
1991:781).






























































f
The
social
production
of
AIDS
as
the
occasion
where
the
HIV
pathogen
triggers
an
illness
that
is


amplified
by
social
forces,
which
are
triggered
by
economic
change
(Schoepf,
1991).



 10

Such
an
approach
opposes
the
notion
that
medical
anthropologists
should
simply

bear
witnessg
to
AIDS
suffering
and
death.
Indeed
some
anthropologists
are

calling
the
failure
to
abandon
the
trope
of
neutral
observer
while
AIDS
decimates

a
continent,
“an
unforgivable
dereliction
of
professional
and
moral

responsibility”
(Bayer
cited
in
Bolton,
1992:288).

Farmer
et
al
have
thrown

down
the
gauntlet
to
their
colleagues
to
produce
full
ethnography,
return
to
the

fieldwork
tradition,
and
to
abandon
anthropologists’
ever‐increasing
reliance
on

surveys,
questionnaires,
and
focus
group
discussions
(Bolton,
1992:298).

In
this

regard,
Farmer
(1992)
established
a
modus
operandi
for
anthropologists
in
the

era
of
HIV/AIDS:



1. Explain
why
AIDS
is
fast
becoming
an
illness
of
the
disadvantaged;

2. Use
ethnography
as
a
cultural
critique;

3. Counter
false
information;

4. Document
the
effects
of
misinformation
and
join
forces
with
community

groups
in
using
such
information
to
develop
cultural
activist
responses
to

the
epidemic;
and


5. Witness
and
honour
the
memory
of
people
who
have
died
from
AIDS

(cited
in
Bolton,
1995:288).12




Although
the
future
of
HIV/AIDS
research
is
dynamic,
the
mainstay
features
of

the
epidemic
–
increasing
prevalence
rates
regardless
of
HIV
prevention

measures,
scientific
failures
to
discover
a
viable
vaccine
or
microbicides,
and
the

increasing
disparity
of
infections
between
the
rich
and
poor,
and
that
of
male
and

female
–
are
indications
that
a
synthesised
anthropological
approach
would
be

useful
in
the
future.
Medical
anthropologist
in
particular
must
invoke
the
spirits

of
Franz
Boas,
himself
a
scientist,
who
asserted
“the
role
of
the
anthropologist
as

scientist
was
to
speak
truth
to
power”
(Rabinow
citing
Boas
in
D’Andrade

1995:402)13
–
and
that
of
Bronisław
Malinowski,
who
offered
that
ethnography

is
the
way
to
“grasp
the
native's
point
of
view,
his
relation
to
life,
to
realize
his

vision
of
his
world”
(Malinowski,
1961:25).14
Successful
AIDS
research
in
Africa,

and
elsewhere
in
the
world,
will
depend
on
anthropologists’
resolve
to
integrate

these
vantage
points
into
biomedical
research
agendas.


AIDS, Condoms and the Biopolitical 
The
history
of
medical
anthropological
contribution
to
HIV/AIDS
research

largely
funded
and
influenced
by
western
biomedicine
should
lead
us
to
at
least

consider
the
controversial
statements
of
Pope
Benedict
XVI.
The
pontiff,
on
the

plane
to
Yaoundé,
Cameroon
in
March
2009
said:
Condoms
aren’t
the
answer
to

the
“scourge”
of
HIV
in
Africa.
“You
can’t
resolve
it
with
the
distribution
of

condoms.
On
the
contrary,
it
increases
the
problem”(cited
in
the
New
York

Times,
2009).15
Was
the
pope
wrong
about
the
power
of
the
condom
to
decrease

HIV
prevalence
rates
in
Africa
or
was
he
wrong
to
challenge
science?

Have

international
health
agencies
been
blinded
to
the
social
milieu
surrounding

condom
use
in
Africa
or
does
the
technological
effectiveness
of
the
condom

appropriately
drown
out
cultural
noise?
Have
anthropologists
from
the
political


























































g
Farmer
(2007)
examines
the
notion
of
bearing
witness
as
one
way
that
anthropologists
can
be


morally
engaged
with
the
powerless.
He
states
that
bearing
witness
consist
of
reporting
the
“stoic

suffering”
of
the
poor,
and
joining
in
“pragmatic
solidarity”
with
the
oppressed.



 11

economist
or
cultural
expert
traditions
used
ethnography
to
lend
a
local

perspective
on
the
acceptability
of
condoms
in
Africa,
or
does
biomedicine
trump

all?




Religion
and
science
remain
at
loggerheads
regarding
condom
promotion
and

there
are
no
signs
that
either
side
will
acquiesce.
Tensions
peaked
when
Cardinal

Alfonso
López
Trujillo,
the
Vatican's
Pontifical
Council
for
the
Family,
said
to
the

BBC
“the
AIDS
virus
is
roughly
450
times
smaller
than
the
spermatozoon.
The

virus
can
easily
pass
through
the
'net'
that
is
formed
by
the
condom”(Bradshaw,

para.
3:2003).16
Health
organizations
fired
back
“intact
condoms…are
essentially

impermeable
to
particles
the
size
of
sexually
transmitted
disease
pathogens,

including
the
smallest
sexually
transmitted
virus”
(UNAIDS,
2004:15).17

International
preoccupation
with
AIDS
in
Sub‐Saharan
Africa
and
the
insistence

on
condoms
as
a
central
way
to
curb
mortality
is
a
key
premise
in
Michel

Foucault’s
biopolitical.
“Biopolitics
deals
with
the
population,
with
the
population

as
political
problem,
as
a
problem
that
is
as
once
scientific
and
political,
as
a

biological
problem,
and
as
power’s
problem”
(Foucault,
1976:245).18
Global
and

local
powers
are
introducing
mechanisms
–
abstinence,
fidelity,
and
condoms–
to

normalise
sexual
behavior;
and
while
Power
cannot
control
death,
it
can
control

death
rates.





This
emergent
power
of
regulation
consists
of
“making
live
and
letting
die”

(Foucault,
1976:247).
To
this
extent,
the
remarks
of
Pope
Benedict
XVI
evoked
a

firestorm
of
criticism
from
heads
of
state,
international
health
agencies,
AIDS

activists,
non‐governmental
organizations
and
members
of
the
general
public.
In

the
New
York
Times,
Rebecca
Hodes
of
the
Treatment
Action
Campaign
in
South

Africa
said
the
pope
should
focus
on
HIV
prevention
through
assisting
in
the

creation
of
an
informed
demand
for
condoms,
and
by
helping
to
close
the

‘condom
gap’
in
the
region.
“Instead,
his
opposition
to
condoms
conveys
that

religious
dogma
is
more
important
to
him
than
the
lives
of
Africans”
(Hodes
cited

in
New
York
Times,
2009).19
In
other
words,
the
pope
was
accused
of
“letting

die.”



 






Figure: Tony Auth, Philadelphia Inquirer, 19 March 2009.20 


 12

In
an
editorial
The
Lancet
demanded
an
apology
from
the
pope,
and
accused
him

of
engaging
in
reckless
behavior
that
could
undermine
AIDS
prevention
efforts
in

the
region.
“By
saying
that
condoms
exacerbate
the
problem
of
HIV/AIDS,
the

Pope
has
publicly
distorted
scientific
evidence
to
promote
Catholic
doctrine
on

the
issue.
Anything
less
from
Pope
Benedict
would
be
an
immense
disservice….”

(de
Leon
et
al,
2009:461).21
A
medical
doctor
and
applied
medical
anthropologist

defended
the
pope’s
position
in
an
editorial
for
The
Washington
Post.
Edward

Green,
then
a
senior
research
scientist
at
the
Harvard
School
of
Public
Health,

offered
that
condom
promotion
has
worked
in
places
such
as
Thailand
and

Cambodia
because
HIV
is
mostly
transmitted
through
commercial
sex.
This
has

enabled
governments
to
address
the
epidemic
by
enacting
condom
use
laws
in

brothels.
In
Africa,
however,
the
pattern
of
the
epidemic
is
different
because

people
often
don’t
use
condoms
in
stable
partnerships
because
it
shows
a
lack
of

trust.
“It's
those
ongoing
relationships
that
drive
Africa's
worst
epidemics”

(Green
cited
in
The
Washington
Post,
2009).h



Pope
Benedict’s
opposition
to
condoms
comes
as
no
surprise
as
the
Catholic

Church
disagrees
with
artificial
contraceptives
under
all
circumstances.
His

predecessor
Pope
John
Paul
II
also
preached
that
abstinence
and
fidelity
should

be
the
focus
of
HIV
prevent,
not
condom
use
(Washington
Post,
2005).22

But
the

current
pontiff’s
assertion
that
the
condom
“increases
the
problem”
represents
a

direct
attack
on
established
scientific
“facts”
proven
by
“laboratory
studies

[which]
show
that
male
latex
condoms
are
impermeable
to
infectious
agents

contained
in
genital
secretions”
(UNAIDS,
2004).23
This
has
transformed
the

pontiff
from
a
sacred
symbol
to
one
of
the
profane
–
a
person
who
distorts

“scientific
evidence”
makes
“false
scientific
statements”
and
doesn’t
care
about

the
“lives
of
Africans.”
The
basis
for
this
strong
counterattack
was
anticipated
in

the
Elementary
Forms
of
Religious
Life
(2008),
where
Durkheim
posits
that
the

values
of
science
have
become
sacred
because
of
its
perceived
role
in
the

wellbeing
of
humankind.
Durkheim
offered
that
if
religion
attacks
the
facets
of

science,
people
would
come
to
the
defence
of
science,
because
the
attack
is
an

offence
to
their
moral
senses
(Durkheim,
2008).24




From
Global
to
Local:
Religion’s
Influence
on
Condom
Promotion
and
Use

While
the
Vatican
and
biomedicine
spar
over
condom
use
in
the
international

arena,
local
African
religious
leaders
and
elder
men
in
several
African
countries

oppose
condom
promotion
on
the
grounds
that
they
lead
to
promiscuity.
This

has
been
documented
in
Uganda
(Obbo,
1995),
Zambia
(Bledsoe,
1991),

Tanzania
(Bujra,
2000;
Coast,
2007),
Zimbabwe
(Bassett
and
Mhloyi,
1991)
and

elsewhere
in
Sub‐Saharan
Africa.
Obbo
(1995)
demonstrates
the
social
power
of

the
hagiarchy
and
gerontocracy
with
a
story
that
severely
damaged
the
AIDS

programme
of
the
school.



























































h
UNAIDS
states:
“The
pattern
of
concurrent
partnerships
is
different
to
the
pattern
of
serial

monogamy
more
common
in
the
west
and
can
result
in
much
higher
rates
of
HIV
transmission

across
communities.
Viral
load
and
'infectivity'
is
much
higher
during
the
three
to
four
week

'acute
infection'
window
period
that
initially
follows
HIV
infection.
The
combined
effects
of

sexual
networking
and
the
acute
infection
spike
in
viral
load
means
that
as
soon
as
one
person
in

a
network
of
concurrent
relationships
contracts
HIV
everyone
else
in
the
network
is
placed
at

risk”
(UNAIDS,
2008,
Focus
on
Multiple
Concurrent
Partnerships).



 13



The
 story
 concerned
 a
 headmaster
 of
 a
 school
 who
 one
 morning

distributed
condoms
to
the
boys.
Before
school
closed,
some
of
the

boys
 came
 to
 him
 and
 said,
 ‘We
 have
 finished.
 We
 want
 more

condoms.’
The
story
was
a
setback
for
the
school’s
AIDS
program.

The
 attitude
 of
 the
 priests
 and
 some
 parents
 was
 that
 ‘condom

ignorance
is
bliss’
which
would
protect
children
from
promiscuity

(1995:81‐82).25



Similar
religious
opposition
to
condom
use
elsewhere
in
Africa
is
duly
noted.

Bledsoe’s
research
on
condoms
and
heterosexual
relationships
(1991)
found

that
in
Zambia,
a
religious
organization
bullied
government
leaders
into

withdrawing
a
booklet
that
advised
students
who
don’t
abstain
from
sex
to
use

condoms,
until
the
content
concerning
condom
use
was
“suitably
amended”

(Bledsoe,
1991:7).
Bujra
(2000)26
found
that
Islamic
religious
leaders
in

Tanzania
opposed
the
sale
of
condoms
in
villages
because
they
feared
providing

access
would
lead
to
illicit
sexual
behavior.
“Condoms
on
sale
in
village
shops?

No,
the
religious
leaders
would
not
condone
that.
It
would
lead
to
immorality”

(mosque
treasurer
cited
in
Bujra,
2000:59).
Amongst
the
Masaai
in
Tanzania,

Coast
(2007)
found
that
Catholics
and
Lutherans
taught,
“condoms
were

ineffective
in
preventing
HIV
infection”
(2007:16).
However,
not
all
local

religious
organizations
were
resistant
to
condom
use.
Schoepf
reports
that
in

1987
the
Catholic
Archdiocese
of
Kinshasa,
DRC,
counseled:
“If
you
can’t
abstain,

use
a
condom.”
Local
Catholic
officials
were
quieted,
however,
when
Pope
John

Paul
II
visited
the
region
and
reiterated
the
Vatican’s
strong
opposition
to

condom
use.
 


Condom
rejection
and
acceptance
in
Uganda
is
often
held
up
as
model
because

the
country’s
ABC
approach
coincided
with
a
reduced
national
HIV
prevalence

from
15
percent
in
1992,
to
5
percent
in
2001
(Schoepf,
2003).27
Men
in
the

upper
echelons
of
power
heavily
endorsed
delayed
sexual
debut
and
fidelity,
but

condom
promotion
faltered
because
of
moral
and
religious
objections.
Condom

use
was
not
embraced
until
President
Fidel
Castro
sent
a
letter
to
President

Yoweri
Museveni,
warning
him
that
one‐third
of
National
Resistance
Army

(NRA)
officers
sent
to
Cuba
for
training
were
infected
with
HIV:



Museveni
 was
 shown
 population
 growth
 projections
 comparing

the
situation
with
and
without
deaths
from
AIDS
if
HIV
continued

to
 spread
 unabated
 in
 Uganda.
 They
 say
 he
 was
 staggered
 by
 the

implications:
 his
 army,
 the
 police
 force,
 the
 teachers
 –
 all

institutions
–
would
be
decimated.
The
cost
in
human
life
could
not

be
 ignored;
 despite
 his
 own
 religious
 conservatism,
 he
 went
 on

national
 media
 shortly
 afterwards
 to
 say
 that
 we
 had
 a
 serious

problem
and
to
endorse
condom
use
(Kiwunuka
cited
in
Schoepf,

561:2003)



Museveni’s
change
of
heart
resulted
in
a
broad
shift
in
societal
attitudes
toward

condoms.
Even
some
Catholic,
Anglican
and
Protestant
religious
leaders

endorsed
the
ABC
strategy
in
full;
and
through
multi‐sectoral
social
mobilization



 14

and
support
from
officials,
condom
promotion
and
sex
talk
became
a
quotidian

affair:



One
 friend
 we
 nicknamed
 ‘ambulance’
 because
 he
 always
 has

condoms
 in
 his
 wallet,
 he
 says
 for
 emergency.
 One
 time
 he
 joked

‘for
emergency
call,
because
I
am
always
there
to
save
your
lives.’

So,
 condoms
 are
 sold
 in
 every
 clinic,
 in
 supermarkets,
 shops
 and

hawkers
have
them.
Prostitutes
in
Kampala
charge
a
condom
fee
if

you
 don’t
 have
 one”
 (a
 man
 in
 his
 twenties
 cited
 in
 Schoepf,

2003:564).



A
Mini­anthropology
of
Condom
Promotion
in
Africa

Shifts
in
societal
attitudes
toward
condoms
parallel
with
the
false
starts
and

subsequent
lessons
learned
by
condom
educators.
Early
condom
promotion
in

Africa
portrayed
AIDS
as
an
illness
acquired
by
sex
workers
and
others
who

engaged
in
illicit
sexual
behavior.
“There
were
posters
with
a
guy
and
a
bottle
of

beer
and
a
lady
in
a
miniskirt.
Those
were
the
ones
that
were
supposed
to
get

HIV”
(Nolen,
2007:65).28
Campaigns
depicted
the
sex
worker
as
a
“reservoir
of

infection,”
which
led
to
the
construction
of
AIDS
as
“a
disease
of
women”
and
of

the
“lower
orders”
–
something
from
which
the
“pure”
needed
protection
–

rather
than
as
the
thing
that
should
be
used
when
one
is
ignorant
of
his
or
her

partner’s
serostatusi
(Schoepf,
2001:341).










Figure 2: Frederick, F.S. (1989), Unknown location


In
Zimbabwe
“an
early
poster
depicted
a
woman
in
a
miniskirt
and
high‐heeled

boots,
dragging
on
a
cigarette,
and
the
caption
exhorted
the
men
to
remain

faithful
to
their
families”
(Bassett
and
Mhloyi,
1991:150).29
In
the
DRC,
“Mass

media
campaigns
stressed
marital
fidelity,
avoidance
of
‘prostitutes’
and
“sexual

vagabondage”
as
well
as
clean
injection
syringes
and
blood
transfusions”

(Schoepf,
1992:229).
Women
who
wished
to
maintain
their
virtue
in
the
eyes
of



























































i
Serostatus
refers
to
the
presence
or
absence
of
specific
substances
in
the
blood.
In
the
instance


of
HIV,
a
blood
test
which
indicates
the
presence
of
antibodies
that
the
body
produces
in

response
to
HIV
infection,
indicates
that
a
person
is
seropositive.



 15

their
male
partner
didn’t
dare
venture
into
shops
to
purchase
condoms,
or
ask

for
protection.
A
Zambian
woman
reiterated
this
to
anthropologists
in
the
field:

“I
have
never
seen
a
condom.
Why
should
I
use
a
condom?
Condoms
are
only

used
by
prostitutes”
(Bond
&
Dover,
1997:
384).30


 
Anthropologists
and
other
social
scientists
initiated
a
movement
from
“risk

groups”
to
“risk
behaviors”
and
condom
programmers,
along
with
that
popular

trend,
began
to
implement
condom
social
marketing
(CSM).
Condom
social

marketing
works
by
creating
an
informed
demand
for
the
product
through

education
and
promotion,
and
then
by
ensuring
that
supplies
are
accessible
to

meet
the
new
demand.
International
organizations
such
as
UNAIDS,
Populations

Services
International
(PSI)
and
the
United
Nations
Population
Fund
(UNFPA),

partner
with
national
governments
to
procure
unbranded
condoms
that
are
then

packaged,
promoted,
and
locally
distributed.

Condom
social
marketing
acts
as
a

“normaliser”
of
condoms,
works
to
reduce
stigma
and
creates
an
environment
in

which
condom
use
is
more
socially
acceptable.









Figure
3:
Trust
Condom
commercial,
PSI
Uganda31


For
example,
PSI
and
the
Malawi
government
introduced
the
Chishango
condom

in
September
1994.
The
brand
means
'shield'
in
Chichewa
and
cost
MK7.00

(US$0.06)
for
a
package
of
three
(PSI
Malawi,
2004).
32
Since
the
launch
of
the

local
brand,
condoms
sales
have
continuously
increased:
In
1994,
4.7
million

condoms
were
sold
and
by
1998
sales
reached
7.1
million.
In
2003,
sales
reached

an
all‐time
high
of
more
than
8.4
million.





 16

 



Figure
4:
PSI
Malawi,
Chishango
condoms
advert


While
CSM
has
led
to
an
increase
in
condom
supply
and
demand,
some

anthropologists
find
fault
with
the
western
premises
for
condomising
Sub‐
Sarahan
Africa.
Bledsoe
(1991)
notes
that
“international
agencies
that
are

scrambling
to
subsidise
and
distribute
condoms
in
Africa”
have
failed
to

appreciate
“the
strength
of
local
beliefs
that
redefine
technologies
that
outwardly

resemble
our
own”
(1991:6).
Indeed
ethnographic
data
show
that
for
some,
in

spite
of
CSM,
the
condom
represents
an
unacceptable
social
distance
between

lovers,
illicit
sex,
mistrust,
and
a
western
intrusion
into
the
African
conjugal
bed.





Other
researchers
have
found
that
increased
condom
distribution
in
some

African
countries
did
not
coincide
with
reduced
HIV
prevalence
rates
(Hearst
&

Chen
2004).

For
example,
in
Botswana,
from
1993
to
2001,
condom
sales

increased
from
one
million
to
3
million,
while
its
HIV
rate
rose
from
27
percent

to
45
percent.
During
the
same
time
in
Cameroon,
condom
sales
increased
from

6
million
to
15
million,
while
HIV
rates
rose
from
3
percent
to
9
percent

(AIDSMark
cited
in
Hearst
&
Chen,
2004:41).33

The
inconsistent
use
of
condoms

is
one
likely
reason
for
the
co‐existence
of
increased
HIV
prevalence
rates
and

condom
distribution.
A
second
reason
for
this
phenomenon
is
the
theory
of
risk

compensation:
“Increased
condom
use
could
reflect
decisions
of
individuals
to

switch
from
inherently
safer
strategies
of
partner
selection
or
fewer
partners
to

the
riskier
strategy
of
developing
or
maintaining
higher
rates
of
partner
change

plus
reliance
on
condoms”
(Richens,
2000:401).
Therefore,
“for
a
condom

promotion
campaign
to
be
beneficial,
it
must
increase
condom
use
substantially

if
the
baseline
use
is
low
and
the
total
number
of
sex
acts
increases
(2000:401).



This
brings
us
back
to
the
statements
of
Pope
Benedict
XVI:
“You
can’t
resolve
it

[HIV]
with
the
distribution
of
condoms.
On
the
contrary,
it
increases
the

problem”
(cited
in
the
New
York
Times,
2009).
Regardless
of
ethnographic
and

statistical
trends,
it’s
unwise
to
rule
out
condom
promotion
in
Africa
because

condom
use
reduces
the
chances
for
mutations
of
the
AIDS
virus,
and
a

subsequent
proliferation
of
strains
(de
Leon
et
al,
2009).
However,
there
are



 17

socio‐economic
evidence
–which
anthropologists
–
not
a
polarizing
religious

figure
–
could
offer
in
the
movement
to
de‐medicalize
HIV
prevention
in
general,

and
condom
promotion
in
particular.
As
Durkheim
offered,
“What
science

disputes
in
religion
is
not
its
right
to
exist
but
the
right
to
be
dogmatic
about
the

nature
of
things,
the
special
competence
it
claimed
for
its
knowledge
of
man
and

the
world”
(Durkheim,
2008:325).
In
this
case,
the
Vatican
and
other
religious

conservatives
are
dogmatic
in
their
claims
that
condoms
are
ineffective
and
lead

to
illicit
sexual
behavior.
While
the
theologians
are
correct
to
emphasize
the

social
side
of
AIDS,
religious
solutions
fail
to
recognize
the
impact
of
poverty,

conflict,
colonialism,
gender
inequality,
migration,
development,
and
other
socio‐
economic
structures,
which
hinder
abstinence,
fidelity
and
condom
use.

“Anthropology,
the
most
radically
contextualizing
of
the
social
sciences,
is
well

suited
to
meeting
these
analytic
challenges,
but
we
will
not
succeed
by
merely

‘filling
in
the
cultural
blanks’
left
over
by
epidemiologists,
physicians,
scientists,

and
policy
makers”
(Farmer,
1998:36).34
As
condom
promotion
remains
a
hotly

contested
issue,
social
scientists
must
unite
with
biomedical
researchers
to
get

rid
of
reductionalism
–
both
biomedical
and
cultural
–
and
inform
condom

promotion,
while
offering
a
sound
analysis
on
the
socio‐cultural
drivers
of
the

AIDS
epidemic.




 18

 

CHAPTER 2 
 
FEMALE BODIES, MALE CONTROL 


While
the
religious
right’s
assertion
that
condoms
are
not
the
solution
to
HIV
in

Africa
comprises
a
granule
of
truth,
the
proposed
alternatives
of
abstinence
and

fidelity
are
as
equally
inadequate
in
addressing
the
vulnerability
of
girls
and

women
to
HIV
infection.
AIDS
researchers
have
called
HIV
a
“biological
sexist”

organism
because
it
is
transmitted
five
times
more
efficiently
from
male
to

female.
“HIV
is
more
highly
concentrated
in
seminal
fluids
than
in
vaginal

secretions
and
may
more
easily
enter
the
bloodstream
through
the
extensive

convoluted
lining
of
the
vagina
and
cervix.
Vulnerable
penile
surface
area
is

much
smaller
–
in
circumcised
men
without
genital
ulcerations,
only
the
urethral

meatus
is
involved…”
(de
Bruyn
et
al
cited
in
Simmons
et
al,
1996:47).35
Women

and
girls
are
more
vulnerable
to
HIV
infection
because
of
their
physical
bodies,

and
their
relative
unequal
status
in
the
social
body
makes
the
condom
a
derisory

solution
to
their
precarious
situation.




The
feminization
of
HIV

Although
women
comprise
the
bulk
of
the
agricultural
labor
force,
supply
most

of
the
semi‐skilled
and
unskilled
work,
and
take
on
most
of
the
“reproductive

tasks,”
which
include
–
child
birthing
and
rearing,
producing
and
cooking
food,

caring
for
their
spouses,
and
tending
to
the
sick
–
women
often
lack
access
to

land,
credit,
education
opportunities,
health
care
choices,
and
political

participation
(Meena,
1992).36
“It
is
one
thing
for
a
woman
to
keep
body
and
soul

together
by
selling
cooked
food
or
vending
a
few
vegetables
at
the
side
of
the

road
because
the
man
does
not
support
her,
but
it
is
another
thing
to
refuse
the

man
his
conjugal
rights
on
the
basis
of
his
refusal
to
wear
a
condom,
which
many

women
cannot
afford
to
buy
in
any
case
(McFadden,
1992:186).37
Women
accept

the
ideology
that
male
partners
can
dominate
their
physical
bodies,
knowing
full

well
that
men
dominate
most
socio‐cultural
aspects
of
life
and
are
the

gatekeepers
to
vital
economic
resources.





While
socio‐economic
status
presents
one
aspect
of
women’s
ability
to
negotiate

the
conditions
of
sex
(including
condom
use),
another
formidable
opposition
is

the
socialization
of
women
in
regards
to
how
a
“proper”
woman
responds
to
her

husband’s
sexual
demands.
Many
African
societies
dictate
that
proper
women

don’t
talk
about
sex,
nor
do
they
say
“no”
to
their
husband’s
advances

(Ssekiboobo,
1992).
38
In
a
Uganda
study,
Wolff
et
al
(2003)
found
that

participants
believed
that
only
“prostitutes”
and
women
who
drank
alcohol

openly
discussed
sex.
Obbo
(1993)
writes
that
traditional
pre‐marital
sex

education
classes
teach
young
Ugandan
women
that
they
should
never
say
no
to

sexual
demands
made
by
their
husbands.
“How
can
a
woman
who
has
been

socialized
never
to
question
the
male
right
to
have
sex
with
her
when
he
so

desires,
as
her
husband,
and
who
rarely
if
ever
discusses
matters
of
sex,
or
even



 19

sees
her
husband
naked,
negotiate
with
him
on
the
matter
of
condom
use?”

(McFadden,
1992:171).
The
short
answer
is,
she
can’t.




Women’s
disempowerment
in
negotiating
sex
and
condom
use
is
further

compounded
by
physical
and
emotional
violence.
Bujra
(2000)
found
that
in

Tanzania
husbands
sometimes
flatly
refused
to
use
condoms,
and
could
use

physical
violence
against
wives
who
made
the
suggestion.
“Some
men
get
drunk

and
they
refuse
these
things,
and
they
can
beat
you”
(an
elderly
woman
cited
in

Bujra,
2001:73).
Male
responses
articulated
the
idea
that
men
exercise
authority

over
their
wife’s
body:
'A
wife
who
asks
you
to
use
those
things
[condoms]
is
not

a
wife
but
a
prostitute'.
'How
can
a
woman
decide?
She
can't
order
her
husband

to
do
things!'
(man
cited
in
Bujra,
2001:73).
During
the
workshop
in
Lushoto,
the

magnitude
of
women’s
precarious
situation
was
reified,
as
one
middle‐aged

village
wife,
who
after
hearing
that
condoms
offered
protection
from
AIDS,

rehearsed
what
she’d
say
to
her
husband:



All
 right
 husband,
 you
 are
 home
 and
 let’s
 celebrate,
 but
 use
 that

condom!
 And
 if
 you
 haven’t
 got
 one,
 then
 I’ll
 go
 and
 sleep

elsewhere!
Or
if
you
keep
forgetting,
then
buy
them
for
me
to
keep!

(cited
in
Bujra,
2001:59)



This
rehearsal
of
women’s
empowerment,
while
entertaining
to
the
women
at

the
workshop,
is
just
that,
a
comical
drama.
Women
who
broach
the
subject
of

sex
or
condom
use
with
her
husband
can
be
beaten
on
the
suspicion
of
taking
on

a
lover
(McFadden,
1992).
I
will
argue
that
based
on
such
ethnographic

narratives,
there
is
little
to
presuppose
that
the
condom
can
protect
women
from

contracting
the
AIDS
virus.
The
condom
loses
its
power
because
gender

stereotypes
silence
women
from
even
speaking
about
safer
sex
less
they
be

considered
a
“prostitute”
(Wolff
et
al,
2000),
risk
beatings
(Bujra,
2000),
or
face

economic
disenfranchisement
(Schoepf,
1992).


 
The
Performance
of
Trust

Condom
use
in
stable
partnerships
is
further
imperiled
by
the
“risk”
and
“trust”

quandary.
“Women
fear
to
ask
in
case
they
are
thought
to
be
infected,
or
immoral

themselves:
‘he
will
ask,
where
have
you
been?!’
A
wife
might
ask
when
she

knows
or
suspects
that
the
husband
is
infected.
But
in
raising
the
issue,
she

undermines
further
the
trust
in
between
them.
And
so,
although
few
women

genuinely
trust
their
husbands,
the
appearance
of
trust
must
be
there”
(Bujra,

2000:76).
Condoms
threaten
to
dissolve
relationships
already
at
risk
because
of

rural‐urban
migration,
insistent
poverty,
and
the
social
milieu
surrounding

formal
and
informal
polygany.



Bledsoe
(1991)
found
that
a
woman’s
suggestion
that
a
male
partner
wear
a

condom
is
the
equivalent
of
accusing
him
of
unfaithfulness,
or
worse,
infection

with
HIV.
In
insisting
on
a
condom,
a
woman
“risks
undermining
economic

support
from
an
outraged
partner”
(1991:7).
Hence
while
condoms
reduce
the

risk
of
HIV
transmission,
the
technology
threatens
the
stability
of
relationships,

and
poor
women
cannot
risk
losing
the
vital
economic
support
of
their
male

partners.




 20

In
contrast
to
the
situation
of
poor
woman
with
little
economic
leverage,

research
has
shown
that
women
with
higher
socioeconomic
status
have
better

outcomes
in
negotiating
safer
sex
(Orubuloye
et
al,
1993;
Wolff
et
al,
2000).

However,
this
economic
independence
does
not
give
women
an
escape
from
the

risk‐trust
quandary
surrounding
condom
use.
Comparative
research
on
Uganda

and
the
DRC
found
that
even
“high
class”
entrepreneurial
women
in
Uganda

failed
to
negotiate
condom
use
with
their
regular
partners
(Schoepf,
2003).
“It
is

not
clear
whether
these
women
believed
that
they
were
not
at
risk
in
these

relationships,
whether
they
felt
unable
to
negotiate
condoms
due
to
the
‘trust’

and
‘respectability’
issues,
or
whether
a
combination
of
these
left
them
in
denial”

(2003:563).
In
Uganda,
the
DRC,
Tanzania,
and
elsewhere
in
Africa,
the
belief

that
women
must
trust
their
partner
is
ubiquitous
and
directly
opposes
condom

messages,
which
implore
individuals
to
use
condoms
unless
both
partners
are

mutually
committed
to
monogamy.
The
inverse
relationship
between
risk
and

trust
is
an
angle
that
condom
programming
could
investigate
in
the
targeting
of

messages.



The
Risky
Sex
of
Married
Couples


It
is
important
to
note
the
difference
between
stable
partnerships
and
marriages

because
the
type
of
union
has
implications
for
women’s
ability
to
say
no
to
sex,

or
unprotected
sex.
Even
with
such
a
distinction,
marriage
is
highly
varied
in

African
societies.
For
example,
anthropologists
would
consider
at
least
thirteen

types
of
partnerships/transactions
a
“marriage”
in
pre‐colonial
Dahomey,
and

Mary
Douglas’
1963
ethnography
on
the
Lele
revealed
the
“coexistence”
of

polyandry
and
polygany
(Guyer,
1991).
In
the
21st
Century,
African
marriages

still
retain
diversity
in
its
stylized
representations.
“Typically,
it
[African

marriage]
is
a
process,
extending
over
a
period
of
months
or
even
years,
as

partners
and
their
families
work
cautiously
toward
more
stable
conjugal

relationships.
At
some
point
in
the
process,
cohabitation
and
sexual
relations

begin,
and
children
may
be
born”
(Bledsoe,
1991:
3).



Gendered
expectations
of
fidelity
characterize
most
African
marital
unions.j

Women
are
socialized
to
be
faithful
and
tolerate
their
husbands’
extramarital

affairs
(Bledsoe,
1991;
Bujra,
2000;
Obbo,
1993;
Orubuloye
et
al,
1991).
Even

though
men
often
have
the
implicit
permission
to
“cheat,”
ethnographic
evidence

revealed
that
men
felt
pressured
to
feign
fidelity.
Rather
than
face
accusations
of

unfaithfulness,
the
husband
would
have
unprotected
sex
with
his
wife
even
if
he

had
unprotected
sex
with
another
woman
(Orubuloye
&
Caldwell,
1993;
Schoepf,

1991;
Bond‐Dover,
1997;
McFadden,
1992).
Since
condoms
interrupt
the
illusion

of
fidelity,
married
women
are
often
reluctant
to
request
or
accept
condom
use

(Chimbiri,
2007;
Schoepf,
1992;
Bassett
and
Mhloyi,
1991).

The
ambiguous

nature
of
unspoken
sexual
commitment
results
in
each
partner’s
reduced
ability

to
negotiate
condom
use.
They
therefore
revert
to
condom‐less
sex.
“[As]
unsafe

sex
implies
closeness,
trust,
honesty
and
commitment
and
leaves
rosy
facades

and
dreams
of
monogamy
and
security
intact”
(Green
cited
in
Bujra,
2000:77).


























































j
The
use
of
the
term
“African”
here
is
in
consistency
with
the
anthropological
findings
on
some
of


the
common
attributes
in
African
marriages.
While
there
are
regional
and
ethnic
variations,
the

multi‐country
ethnographical
accounts
offer
similar
constructions
on
the
gendered
expectations

of
marital
fidelity.



 21

The
risk‐and‐trust
charades
of
married
people
was
explored
in
three
rural

districts
in
Malawi.
Research
found
that
while
Malawi
women
have
used
divorce

as
an
option
to
protect
themselves
from
HIV,
Malawi
men
have
responded
by

reducing
sexual
partnerships,
being
more
selective
of
extramarital
partners,
and

using
condoms
in
outside
sexual
liaisons
(Chimbiri,
2007).39
“To
both
married

men
and
women,
as
evidenced
with
the
discussions
of
men’s
and
women’s
social

networks,
the
condom
for
use
in
unacceptable
and
suspicious
sexual

partnerships”
(2007:1113).
To
the
women,
the
condom
embodies
an
intolerable

threat
to
the
marriage
and
is
consistently
associated
with
“bad”
sex:
infidelity,

transactional
sex,
and
a
husband’s
dissatisfaction
with
sex
at
home:



At
one
time,
I
found
condoms
inside
the
pockets
of
my
husband’s

pair
 of
 trousers.
 So
 I
 asked
 my
 husband:
 “What
 are
 these
 things

for?”
He
said:
“I
just
move
with
them.”
I
asked
him:
“How
do
you
do

that?”
 He
 replied:
 “Ah,
 in
 case
 I
 grab
 a
 woman
 who
 surrenders

herself
 to
 me,
 I
 do
 not
 want
 to
 contract
 a
 sexually
 transmitted

disease.”
At
one
time,
I
get
annoyed.
I
took
all
of
the
condoms
and

burnt
them.

Then
he
said:
“So
you
want
me
to
contract
an
STI
and

then
 we
 will
 all
 have
 it.”
 I
 said
 to
 him:
 “Why
 do
 you
 need
 these

condoms?
Why
should
you
do
that
yet
you
have
two
wives?
If
you

want
a
woman,
you
should
just
come
to
one
of
us.
If
you
feel
that

we
do
not
satisfy
you,
why
don’t
you
just
leave
us?”
Then
he
said:

“Ok.”
 But
 after
 some
 time,
 I
 just
 realized
 that
 he
 brought
 some

more
 condoms
 (rural
 married
 woman,
 37,
 cited
 in
 Chimbiri,

2007:1111).



Introducing
condoms
into
Malawi
marriages
also
faces
cosmological
difficulties,

as
Malawi
people
believe
that
marital
sex
comes
from
God
and
comprises

elements
that
should
not
be
altered:
1)
Sex
is
a
“natural
candy”
to
be
enjoyed,

and
2)
Sex
is
purposed
to
produce
children.
As
one
young
married
woman
said,

“With
a
condom,
we
get
nothing.
Can
you
chew
a
sweet
together
with
its
packet?

Can
you
get
the
sweetness,
you
can’t?

So
what
we
want
is
the
whole
of
the
thing

(the
penis)
should
enter
into
me
and
just
that
so
that
we
can
feel
the
sweetness”

(young
married
woman,
cited
in
Chimbiri,
2007:1111).

The
symbolic
nature
of

the
condom
interrupts
the
symbolic
nature
of
marriage,
and
condoms
introduced

into
marriage,
meant
that
the
union
wasn’t
really
a
marriage
at
all.

Although

condom
use
has
increased
for
outside
partners,
when
the
extramarital
partner
is

considered
“risky,”
the
social
construction
of
marriage
makes
it
unlikely
that

marital
condom
use
will
increase
anytime
soon
(Chimbiri,
2007).




The
examples
from
Tanzania
and
Malawi
illustrate
that
in
order
for
condom

stigmas
to
dissipate
the
condom
must
first
be
socially
accepted
as
a
legitimate

tool
to
prevent
a
potentially
fatal
illness
caused
by
a
microbiological
event,

nothing
else.

The
Ugandan
president’s
public
promotion
of
condoms
via
the

mass
media,
and
the
condom’s
subsequent
acceptance
by
religious
and

educational
institutions
is
one
example
of
how
the
condom
can
overcome
stigma.

Based
on
applied
anthropological
outcomes
in
the
DRC,
Schoepf
(1992)
has

suggested
interventions,
which
train
couples
on
communication
to
assist
them
in

speaking
about
their
sexual
histories,
and
to
help
them
make
a
realistic
risk



 22

assessment.




The
Symbolic
and
Material
Value
of
Fertility


It
is
important
to
note
that
rural
households
are
typically
larger
than
those
of

urban
dwellers,
and
that
although
most
African
households
remain
in
rural

areas,
persistent
economic
crises
have
prompted
many
to
reconsider
traditional

family
sizes.
In
general,
fertility
is
declining
in
the
Sub‐Saharan
Africa
region,
and

there
are
many
unmet
reproductive
health
needs
that
prevent
some
women

from
limiting
fertility
(Population
Reference
Bureau,
2008).
Yet
many
women

feel
pressured
to
bear
many
children,
in
spite
of
personal
desires
for
smaller

families.
This
can
be
linked
to
some
mainstay
characteristics
of
African

households:k
“They
are
mostly
rural,
they
are
mostly
patriarchal
and
hierarchal,

they
give
great
emphasis
to
perpetuation
of
the
lineage,
they
are
frequently

polygnous,
[and]
they
are
not
nuclear,
embracing
kinship
networks
(Makinwa‐
Adebusyoe,
2001:125).40




Against
this
socio‐cultural
backdrop
motherhood
is
central
to
womanhood
and

often
provides
legitimacy
of
a
woman’s
sexuality.
In
addition,
women
in
Africa,

and
elsewhere
in
the
world,
are
often
socialized
to
believe
that
it’s
their
duty
to

have
children,
sons
in
particular
(Carovano,
1991).41

As
one
Ugandan
young

woman
being
counseled
on
HIV
said,
“Babies
and
condoms
don't
go
together,

non‐penetrative
sex
is
no
sex
at
all
for
a
man,
and
it
is
a
woman's
responsibility

to
bear
a
child”
(fieldwork
by
Kaleeba
cited
in
Carovano,
1991:6).
Being
childless,

or
failing
to
produce
more
offspring
has
serious
implications
for
women
and
men

in
Africa
(Bledsoe,
1991).
“Women
can
be
divorced
and
men
humiliated
for
not

producing
children,
and
the
partner
who
cannot
or
will
not
have
children
is
soon

abandoned”
(1991:3).




Guyer
(1990)
42
looks
beyond
the
symbolism
of
fertility
to
the
economic
benefits

accorded
to
mothers
who
participate
in
“polyandrous
motherhood,”
or
having

children
by
more
than
one
father.
Guyer
draws
on
research
by
Caldwell
(1976),43

who
argues
that
in
Africa
there
is
a
material
benefit
to
high
fertility
because

resources
flow
from
junior
to
senior,
and
Cain44
(1984)
who
posits
that
women’s

status
in
patriarchal
societies
necessitates
access
to
male
kin
–
sons
in
particular.

She
pursues
the
theory
that
“children
can
be
a
means
of
creating
ties
for
oneself

in
a
lateral
strategy
of
network‐building
and
giving
‘opportunities
for
political

and
social
mobility’
to
the
parental
generation,
particularly
women”
(1990:3)
In

such
a
strategy,
“children
mediate
the
relationships
which
can
hardly
be
set
up

or
maintained
in
any
other
way,
including
marriage
itself”
(1990:3).
Although

men
have
more
outright
access
to
material
resources,
the
links
that
a
child

provides
are
significant
enough
for
an
impotent
man
to
purchase
the
pregnancy

of
another,
because
a
woman
will
not
remain
in
a
childless
relationship
unless

she
no
longer
intends
to
have
children
(Guyer,
1990).



Condom
use
in
contexts
where
polyandrous
motherhood
is
the
norm
would

interrupt
a
woman’s
primary
mode
of
economic
support,
that
is,
having
children



























































k
The
author
posited
that
regardless
of
regional
variations
these
characteristics
are
often
the
rule


rather
than
the
exception.





 23

through
multiple
and
concurrent
sexual
partnerships.
UNAIDS
has
ratcheted
up

its
focus
on
these
types
of
sexual
relations,
calling
it
one
of
three
critical
factors

driving
the
AIDS
epidemic
(UNAIDS,
2008a).45
McFadden
(1992)
cautions
that

international
condemnation
of
poly‐partner
sexual
relations
and
emphasis
on

the
benefits
of
the
traditional
forms
of
marriage/partnership
is
misplaced

because
such
relationships
have
failed
to
protect
women
from
HIV
infection
thus

far:
“The
majority
of
married
men
are
not
necessarily
practicing
safer
sex”
and

“in
most
case
women
do
not
have
enough
leverage
to
refuse
having
unprotected

sex”
in
most
sexual
relationships
(1992:165,
186).



While
polyandrous
motherhood
is
a
hard‐won
aspect
of
African
female
sexuality

(McFadden,
1992),
at
the
heart
of
the
practice
is
the
age‐old
emphasis
on

fertility.
Condom
promotion
has
yet
to
successfully
address
the
fertility
question

in
the
demographic
of
women
who
are
having
the
riskiest
sex,
that
is,
married

women.
Anthropologists
have
noted
that
this
failure
has
rendered
the
condom

useless
to
many
(married)
women.
“To
provide
women
exclusively
with
HIV

prevention
methods
that
contradict
most
societies’
fertility
norms
is
to
provide

many
women
with
no
options
at
all”
(Carovano
cited
in
Simmons
et
al,
1996:47).

Schoepf’s
(1992)
work
in
the
DRC
exemplified
a
safer
sex
model
for
couples

trying
to
get
pregnant;
for
example,
when
attempting
to
conceive,
the
couple

could
have
condom‐less
sex,
and
when
procreation
was
not
a
preoccupation,
the

couple
could
use
a
condom.
“This
solution
is
admittedly
imperfect
but
more

realistic
than
advising
people
to
abstain
from
procreation.
It
would
[also]
reduce

the
risk
of
partner
infection
and
perinatal
transmissionl
in
stable
relationships”

(1992:233).
For
the
most
part,
the
condom
is
not
a
useful
ally
in
HIV
prevention

in
situations
where
there
are
widespread
preoccupations
with
fertility.





























































l
Perinatal
transmission
of
HIV
defines
the
transmission
of
HIV
from
mother
to
child
during


pregnancy,
delivery,
or
breastfeeding.



 24

 

CHAPTER 3 
 
THE SOCIAL AND COSMOLOGICAL DIMENSIONS OF SEX 


Notions
of
good
sex
are
culturally
specific
and
implicitly
tied
to
personhood.

People
have
sex
to
experience
pleasure,
procreate
or
gain
profit.
“Over
the
past

millennia,
sex
has
assumed
a
complex
and
varied
character,
impacted
upon
by

culture,
customs,
norms
of
behavior,
morals
and
by
the
commoditization

process”
(McFadden,
1992:167).
In
some
African
societies
“successful
sex”
and

the
condom
are
diametrically
opposed
because
it
diminishes
fertility,
often
the

implicit
goal
of
sex.
In
Zambia,
the
condom
prevents
“good
sex”
because
it

prolongs
the
sex
act,
a
characteristic
of
intercourse
viewed
unfavourably
because

longer
sex
reduces
the
number
of
“rounds”
or
possible
ejaculations.





Condoms
also
prevent
the
‘mingling’
of
the
male
and
female
sexual
secretions

that
are
believed
necessary
for
procreation
in
Tanzania,
Zambia
and
the
DRC.

Lastly,
the
condom’s
principal
job
of
preventing
semen
from
entering
the
womb

interferes
with
the
vaginal
ejaculation
of
semen
reckoned
necessary
for
the

woman
to
orgasm
in
the
DRC
and
Zambia.
Though
these
beliefs
are
highly
varied,

the
findings
have
one
aspect
in
common:
cultural
meanings
of
sex
directly

oppose
and
can
prevent
condom
use
–
even
in
areas
where
participants
are

aware
of
AIDS
and
the
condom’s
prophylactic
effect.

I
have
chosen
Heald’s

(1995)
examination
of
”mingling,”
the
East
African
metaphor
for
coitus
and

reproduction,
because
of
its
implications
for
condom
promotion
and
use.




Mingling
cannot
take
place
if
the
couple
uses
a
condom
because
it
requires
the

‘white
blood’
of
semen
and
the
‘red
blood’
of
menses.




In
 some
 cases
 the
 white
 blood
 is
 seen
 to
 effectively
 fix
 the

menstrual
 blood
 inside
 the
 woman,
 and
 the
 specific
 powers

attributed
to
the
white
versus
the
red
blood
vary.
However,
in
its

general
form,
the
belief
has
three
main
implications:
first,
that
the

child
is
formed
jointly
from
the
bodily
substances
of
both
husband

and
 wife;
 second,
 that
 repeated
 intercourse
 is
 necessary
 for

conception
 and
 for
 the
 growth
 of
 the
 foetus
 in
 the
 womb;
 third,

very
 frequently
 the
 most
 fertile
 time
 of
 the
 month
 is
 identified

with
 menstruation
 and
 the
 days
 immediately
 following
 it

(1995:498).46




The
use
of
condoms
would
interrupt
the
moral
responsibility
of
both
parents
to

develop
their
unborn
child,
but
in
situations
where
an
individual
has
multiple

and
concurrent
sexual
partners,
or
in
the
case
of
a
serodiscordant
couple,

‘mingling’
greatly
increases
the
risk
of
HIV
transmission.




Representations
of
semen


In
the
AIDS
epidemic,
international
health
organizations
have
progressed



 25

northern
biomedical
hegemony
regarding
the
construction
of
AIDS,
the
symbolic

value
of
semen,
the
meaning
and
purpose
of
sex,
and
the
pro‐creative
process.

Condom
promotion
literature
instructs
practitioners
to
recount
that
semen
is

scientifically
proven
to
be
a
simple
biological
substance
that
either
impregnates

a
woman,
or
transmits
pathogens
to
her
or
the
fetus.

For
example,
literature

from
UNFPA
(2007)
cites:
Semen
is
the
fluid
that
protects
and
carries
the
sperm

to
fertilize
an
egg
(ovum)
in
human
reproduction.
All
men
inevitably
“waste”

billions
of
sperm
and
liters
of
semen
during
a
lifetime.
They
are
wasted
in
a

condom,
washed
out
of
a
woman’s
vagina,
or
re‐absorbed
into
the
man’s
body

because
he
has
not
ejaculated.
All
this
is
completely
normal
and
does
not
cause

any
harm
to
the
man
or
the
woman
(2007:49).47





However,
notes
from
the
field
suggest
that
many
cultures
do
not
share
the
same

views
as
UNFPA,
and
also
do
not
put
much
purchase
into
the
use
of
condoms.

Coast
(2007)
analysed
the
socio‐cultural
significance
of
sperm
and
context
of

condoms
amongst
the
rural
Maasai
and
found
that
the
local
populations
viewed

condoms
negatively
because
they
counter
fertility,
“waste
semen,”
are
“not

Masaai”
and
interrupt
the
woman’s
sexual
pleasure.
The
Maasai
also
believe
that

semen
is
important
for
the
physical
growth,
and
development
of
the
breasts
of

an
entito
–
a
young,
circumcised
girl
(Coast,
2007).
“Murran
[circumcised
male

who
becomes
a
warrior]
are
considered
the
epitome
of
healthiness,
therefore,

their
sperm
is
best
for
pre‐pubescent
girls”(2007:11).48
Through
sexual

initiation
and
the
giving
of
semen,
the
murran
is
instrumental
in
shaping
societal

approval
of
the
fertility
of
the
entito.




Research
participants
agreed
that
it
would
be
“impossible”
to
introduce
condoms

in
the
murran­entito
relationship;
and
condoms
would
be
undesirable
in
most

Maasai
contexts
because
of
the
highly
symbolic
value
of
semen.
Coast
concluded

that
condoms
as
an
AIDS
prevention
technology
amongst
the
Masaai
should
be

re‐evaluated
and
other
methods
that
are
more
compatible
with
the
cultural

values
of
semen
should
be
investigated.
“Where
sperm
[and
fertility]
are
highly

valued,
microbicidesm
might
represent
a
real
alternative
to
condoms
for
HIV

prevention”
(2007:22).49




Condoms
and
good
sex
don’t
mix


There
are
also
notions
of
masculinity,
male
potency
and
good
sex
–
represented

by
semen.
In
Chiawa,
a
rural
chieftaincy
in
Lusaka
Rural
Province,
semen
holds

such
importance
that
the
grandfather
(or
elder
male
relative)
of
a
young
male
is

responsible
for
initiating
a
course
of
potency
medicine
(usually
an
herbal

mixture),
which
is
continued
throughout
manhood.
“In
consistency
it
[semen]

should
be
thick,
cream
coloured
and
sticky”
(Bond
&
Dover,
1997:380).
The

quality
is
important
because
it’s
inversely
related
to
the
number
of
ejaculations

(rounds),
a
key
component
of
good
sex.
The
first
“round”
holds
prime

importance,
as
this
is
the
time
when
the
man’s
“bullets”
should
penetrate
deep

inside
the
woman,
an
action,
which
also
infers
that
the
primary
cultural
concern



























































mVaginal
microbicides
are
proposed
as
a
female‐initiated
method
to
reduce
the
risk
of
male‐to‐
female
transmission
of
HIV
and
other
STIs.
Once
a
viable
option
is
developed
the
product
form

would
occur
as
vaginal
creams,
gels,
foam,
or
rings
(Population
Council,
2008).




 26

with
sex
is
reproduction.




Both
men
and
women
agreed
that
it
was
insufficient
for
a
man
in
his
prime
to

have
only
“one
round.”
An
older
woman
said,
“More
than
two
rounds
“‘show

love;
that
a
woman
is
good
and
a
man
is
strong’”(cited
in
Bond
&
Dover,

1997:381).

The
dominant
cliché
retold
to
anthropologists
was
that
penetration

and
vaginal
ejaculation
without
condoms
is
shorthand
for
good,
proper
sex
in

Chiawa
(1997:382).
Through
vaginal
ejaculation
a
man
fulfills
his
procreative

role,
sexually
satisfies
the
woman,
and
perpetuates
the
cultural
value
of
“good

sex”
although
participant
responses
revealed
a
conflict
between
cultural
beliefs

on
good
sex,
constructions
of
manhood,
and
wishes
to
avoid
pregnancies
or

sexually
transmitted
infections
(Bond
&
Dover,
1997).
While
the
study
concluded

that
condom
promotion
shouldn’t
be
completely
abandoned,
research
on
the

migrant
farm
suggests
that
due
to
culturally
specific
sexual
practices
and
beliefs

concerning
sex,
condom
promotion
should
take
place
alongside
other
safer
sex

methods,
(Preston‐Whyte
cited
in
Bond
&
Dover,
1997:388).




To
date,
the
only
alternative
safer
sex
methods
are
abstinence
and
fidelity,
which

leads
us
back
to
relying
on
“heroic”
behavior
to
prevent
HIV.
Can
the
promotion

of
safer
sex
lead
to
sustainable
behavior
change
and
subsequent
reduced
HIV

prevalence
rates?
Or
do
cultural
attitudes
regarding
sex
presuppose
the
adoption

of
sex‐positive
strategies? Biomedical
experts,
through
the
investment
of
$868

millionn
in
AIDS
vaccine
research
and
development
in
2008
alone,
have
implied

that
behavior
changes
are
unlikely
to
occur
at
a
pace
that
will
slow
the
rates
of

infection
in
the
AIDS
epidemic.50
But
anthropologists
(Schoepf,
1991;
Heald,

1995,
Obbo,
1993)
argue
that
Africa’s
long
history
of
cultural
adaptation
in

response
to
forces
such
as
colonialism
and
modern
warfare
should
be
a
strong

indication
of
the
continent’s
capacity
to
address
the
threat
of
AIDS.
Indeed
one

man
responded:



They
shouldn’t
think
that
African
men
can’t
change.
That’s
wrong.

Only
 don’t
 ask
 the
 impossible.
 Men
 wont
 become
 monogamous

over
night.
They
[condoms]
aren’t
pleasant.
Nevertheless,
between

life
and
the
risk
of
a
horrible
death,
men
like
ourselves
will
choose

life.
 It’s
 wrong
 to
 say
 we
 can’t
 change.
 Since
 we
 all
 want

descendants,
we
have
to
lick
AIDS
(cited
in
Schoepf,
1991:752).51

 


























































n
Figures
taken
from
UNAIDS,
2009.



 27

 

CHAPTER 4 
 
THE SOCIAL PRODUCTION OF AIDS 
 
While
the
cultural
premises
for
condom
rejection
remains
at
loggerheads
with

the
scientific
proof
for
condom
promotion,
Farmer
(1999)
cautions
against
the

conflation
of
cultural
practices
and
structural
violence.

For
example,
the
Yoruba

women
of
the
Ibarapa
District
carry
out
the
culturally
acceptable
practice
of

having
multiple
and
concurrent
sexual
partnerships,
but
this
sexual
behavior
is

necessitated
by
economic
and
social
need.
UNAIDS
has
cautioned
that
this

practice
in
particular
places
individuals
at
an
increased
risk
to
AIDS
because
the

“viral
load
and
'infectivity'
is
much
higher
during
the
three
to
four
week
'acute

infection'
window
period
that
initially
follows
HIV
infection”
(UNAIDS,
2008).



Economically
necessitated
(informal)
polyandry,”
polyandrous
motherhood,
and

reliance
on
survival
sex
are
structural
factors
that
make
women
in
particular

more
vulnerable
to
AIDS.
This
coupled
with
the
physiology
of
the
female
body

conspire
to
entrap
resource‐poor
women
in
a
complex
web
of
risk.
This

assumption
is
supported
by
statistics
from
UNFPA,
which
state
that
the
majority

of
individuals
living
with
HIV
in
the
Sub‐Saharan
African
region
are
women

(UNFPA,
2008).52
UN
agencies
refer
to
this
alarming
trend
as
the
“feminization
of

AIDS
and
poverty.”
Farmer
(1996),
however,
calls
their
sickness
“a
result
of

‘structural
violence’
because
it
is
neither
nature
nor
pure
individual
will
that
is
at

fault,
but
rather
historically
given
(and
often
economically
driven)
processes
and

forces
that
conspire
to
constrain
individual
agency”
(1996:23).
53

In
the
sections

below
I
will
examine
how
socio‐economic
phenomena
such
as
structural

adjustment
programmes
(SAPs),
urban‐rural
migration,
and
mining
work
coexist

with
sexual
risk
taking
implicated
in
the
transmission
of
the
AIDS
virus.





The
Sexual
Consequences
of
Poverty

The
oil
shock
of
the
1970s
sent
many
Sub‐Saharan
African
economies
into
a

downward
spiral.
Financial
institutions
were
eager
to
lend
as
they
figured

sovereign
entities
would
not
default
on
loans;
but
as
countries
became
heavily

indebted,
they
couldn’t
repay
and
had
to
agree
to
International
Monetary
Fund

(IMF)
designed
reforms
known
as
structural
adjustment
programmes
(SAPs).

Although
there
is
no
unitary
SAP,
some
measures
include
the
introduction
of

user
fees
for
primary
healthcare
and
education,
increased
interest
rates,
the

privatization
of
public
enterprises
and
trade
liberalization.




Barnett
and
Blackwell
(2004)54
argue
that
it
is
difficult
to
measure
the
direct

impact
of
“discrete
economic
variables”
on
HIV
transmission
rates
but
“the

widespread
adoption
of
SAPs
in
sub‐Saharan
Africa
has
been
synchronic
with

significant
increases
in
HIV
prevalence
rates”
(2004:9).
For
example,
increased

interest
rates
and
the
privatization
of
public
enterprises
can
lead
to
job

shortages
and
more
women
engaging
in
transactional
sex
to
survive
to
meet

household
needs.
Trade
liberalization
is
often
the
culprit
in
reduced
subsistence



 28

farming,
of
which
women
are
the
main
participants;
and
deregulation
of
the

economy
can
lead
to
an
increase
in
food
and
petrol
prices.

Farmer
et
al
(1996)

argued
that
SAPs
pushed
families
into
a
state
of
desperation
in
which
people

were
reduced
from
eating
two
or
three
meals
per
day,
to
one
or
none.
While

economists
are
loathed
to
connect
the
impact
of
SAPs
on
HIV
prevalence
rates,

micro‐level
ethnography
of
poor
women
selling
their
bodies
to
feed
their

families
can
be
linked
to
this
wider
macro‐level
political
economy
(Schoepf,

2003).
“Some
exchange
sex
for
the
means
of
subsistence.
Others
enter
sex
work

at
the
behest
of
their
families,
to
obtain
cash
to
purchase
land
or
building

materials,
to
pay
a
brother’s
school
fees,
or
to
settle
a
debt.
Still
others

supplement
meager
incomes
with
occasional
resort
to
sex
with
multiple

partners.
Married
or
not,
the
deepening
crisis
propels
many
to
seek
‘spare
tires’

or
‘shock
absorbers’
to
make
ends
meet”
(Schoepf
cited
in
Farmer,
1996:24)



Poor
women
are
not
the
only
ones
compelled
to
exchange
sexual
favours
for

economic
survival.
Transactional
sex
is
also
an
upward
mobility
strategy
of

women
in
male‐dominated
professions.
Studies
have
shown
that

businesswomen,
entrepreneurs,
and
traders
rely
on
sexual
strategies
to
obtain

commercial
goods
in
the
DRC
(Schoepf,
1992),
Ghana
(Ankomah
&
Ford,
1994)55

and
Zambia
(Mwale
&
Burnard,
1992).56
Professional
women
are
also
forced
or

coerced
into
sexual
relationships
with
their
male
supervisors
or
co‐workers
in

places
such
as
Uganda,
and
on
commercial
farms
in
Zambia.
Bond
and
Dover

(1997)
offered
that
although
uncertain,
“it
appears
in
such
compromised

circumstances,
condoms
are
rarely
used”
(386),
thereby
increasing
the
risk
of

HIV
transmission
in
these
sexual
encounters.

Until
the
poverty
of
women
is

addressed,
condom
promotion
will
face
an
uphill
battle.
The
more
economically

desperate
a
woman
is,
the
less
likely
she
will
insist
on
protection
–
and
grinding

poverty
creates
an
environment
in
which
fatalism
and
sexual
risk
taking
prevail

over
optimal
sexual
behaviors.




Masculinity,
Migration,
and
Sexual
Risk
Taking

The
social
milieu
implicated
in
rural‐urban
migration,
lorry
driving,
and
mining

have
created
a
complex
dynamic
in
which
African
men
face
an
increased
risk
to

HIV
infection.
For
example,
the
construction
of
“reproductive
tasks”
as
“women’s

work”
coexists
with
men
seeking
“wives”
in
multiple
locations
to
ensure
that

property
is
maintained,
and
the
needs
for
sex
and
intimacy
are
met.
Ulin
(1992)

noted
that
in
Central
and
Eastern
Africa
“Urban
men
can
manage
more
efficiently

if
they
have
a
wife
in
the
city
and
another
at
home
to
manage
the
lands”

(1992:66).57
Along
the
colonial‐developed
Nigerian
transport
system,
Orubuloye

et
al
(1993)
found
that
lorry
drivers
established
a
semi‐permanent
home
at

every
stop.
“[T]
hey
prefer
the
comforts
of
home
–
home‐cooked
food,
familiar

surroundings,
their
own
bed,
and
female
friendship
and
sex
to
anonymous

entertainment
and
commercial
sex
(Orubuloye
et
al,
1993:
44).58
This

characterization
is
contrary
to
the
popular
belief
that
lorry
drivers
are

consorting
with
sex
workers,
as
there
are
few
sex‐workers
proper
in
Africa.

(Basset
&
Mhloyi,
1991)
–
rather
their
sexual
practices
can
be
contrasted
with

the
socio‐economic
structures,
which
facilitate
multiple
sexual
partnerships
and

HIV
infection.






 29

While
rural‐urban
migrant
men
have
relied
on
“informal
polygany”
as
a
coping

mechanism,
mine
workers
have
responded
to
the
perils
of
working
in
the
South

African
gold
mines
by
shaping
meaningful
social
identities
and
masculinities.


One
man
recounted
the
terror
he
experienced
the
first
time
he
rode
in
the
“cage”

(lift)
to
the
worksite
located
up
to
3
kilometers
underground.
“They
told
me
that

in
this
situation
you
must
know
that
now
you
are
in
the
mines
you
are
a
man
and

must
be
able
to
face
anything
without
fear”
(mine
worker
cited
in
Campbell,

2004:150).
A
“macho
sexuality”
often
accompanied
the
bravado,
fearlessness,

and
persistence
needed
to
survive
in
such
circumstances.
The
anthropologist

recorded
the
following
dominant
clichés:
“There
are
two
things
to
being
a
man:

going
underground,
and
going
after
women”
and
“a
man
must
have
flesh‐to‐
flesh”
(mine
workers
cited
in
Campbell,
2004:152).



Although
the
mines
launched
multiple
campaigns
that
promoted
HIV/AIDS

awareness
and
condoms,
Campbell
(2004)59
posits
the
“stressful
and
socially

impoverished
living
conditions”
under
which
the
miners
live,
contribute
to

loneliness
and
less
opportunities
for
meaningful
intimate
and
social

relationships.
These
structural
factors
are
manifested
in
sexual
risk
taking
such
a

having
multiple
sexual
partners
without
the
use
of
condoms.
The
sexual
risk

taking
of
miners
can
be
compared
to
the
larger
risks
miners
take
on
the
job:
As

one
miner
said,
there
is
no
protection
from
fate:
“The
rock
can
just
fall
anytime

and
we
try
not
to
think
about
that”
(miner
cited
in
Campbell,
2004:149).
One
can

easily
juxtapose
AIDS,
a
seemingly
uncontrollable
fatal
syndrome,
and
the

common
rock
accidents,
to
understand
why
condoms
are
of
little
interest
to

those
living
in
dire
circumstances
that
override
the
invisible
threat
of
the
AIDS

virus.
Although
HIV
prevalence
rates
are
typically
high
in
the
mines
(Campbell,

2004),
protecting
oneself
from
infection
will
remain
a
lesser
preoccupation
than

the
“warmth”
and
intimacy
that
“flesh‐to‐flesh”
sex
offers
to
lonesome
miners
in

deplorable
living
conditions.



 30

 CONCLUSION 


Condoms
are
effective
in
preventing
the
transmission
of
the
AIDS
virus,
however,

ethnographic
evidence
shows
that
populations
in
the
sub‐Saharan
African
region

often
face
economic,
social
and
cultural
constraints
to
using
condoms.
Such

constraints
are
often
marginalized
in
the
discourse
on
HIV
prevention,
where
the

focus
in
placed
on
the
epidemiological
patterns
of
transmission
and
the

biotechnologies
proven
to
reduce
risks.
This
dissertation
is
calling
for
medical

anthropologists
to
lead
the
de‐medicalization
of
HIV
prevention,
and
to
advocate

for
a
more
holistic
approach
that
considers
the
social
side
of
AIDS.




Anthropologists
have
the
tools
to
reframe
the
debate
on
HIV
prevention,
and

lend
support
to
a
new
approach.
For
example,
research
has
uncovered
ways
that

HIV
prevention
can
work
with
cultures
to
promote
condom
use,
and
other
sex‐
positive
behaviors.
For
example,
research
in
the
DRC
suggests
that
in
cultural

contexts
where
emphasis
is
placed
on
lineage,
the
health
of
the
infant
can
be

stressed
as
a
reason
to
use
condoms
with
serodiscordant
couples,
or
when
one

partner
is
suspected
of
being
seropositive.
This
focus
would
avoid
the
risk‐trust

quandary,
which
poses
a
barrier
to
condom
use
in
stable
partnerships.o



In
cultures
where
bodily
fluids
hold
social
and
cosmological
dimensions,
health

workers
could
collaborate
with
traditional
healers
to
reinvent
beliefs
on
the
role

of
semen
in
procreation.
Applied
anthropological
work
in
the
DRC
found
that

traditional
healers
were
able
to
reinterpret
the
East
African
metaphor
of

“mingling”
to
mean
that
the
father
should
focus
on
his
wife
and
not
have

extramarital
affairs
while
she
is
pregnant
with
the
child.
This
intervention
not

only
served
to
reduce
the
risk
of
perinatal
transmission
of
HIV,
but
it
also

prevented
the
emergence
of
harmful
counter
discourses
from
traditional
healers

who
might
feel
marginalized
or
excluded
from
the
biomedical
dominated

HIV/AIDS
debate.p




Anthropologists
must
lobby
for
the
inclusion
of
interventions,
which
address
the

co‐factors
of
HIV
transmission,
such
as
gender
inequality,
on
HIV/AIDS

prevention
research
agendas,
if
Africa
is
to
ever
witness
a
true
decrease
in
HIV

prevalence
rates,
rather
than
stabilization
attributed
to
“die‐off.”

In
this
regard,

ethnographic
trends
support
the
position
of
African
feminists
who
state
that
men

are
the
solution
to
HIV.
In
contexts
where
men
hold
the
social,
political,
and

physical
power
over
women,
the
condom,
a
male
applied
device,
depends
on
the

full
acceptance
and
cooperation
of
men.
Until
the
social
marketing
of
the
female

condom
takes
place,
men
must
be
the
main
targets
of
condom
promotion.



Lastly,
the
grinding
poverty
which
is
common
to
many
African
societies
with

high
HIV
prevalence
rates
must
be
addressed
by
international
agencies
invested

in
reducing
the
illness
and
death
associated
with
AIDS.
Focussing
on
abstinence,

fidelity,
and
condoms
offer
very
little
to
women
who
sell
their
bodies
for


























































o(Schoepf,
1992)

p(Schoepf,
1992)



 31

subsistence,
and
men
who
work
in
deplorable
conditions
that
facilitate
a

fatalistic
attitude,
which
opposes
preoccupations
with
health
and
longevity.
Such

assertions
are
qualitative
in
nature,
but
persistent
HIV/AIDS
prevalence
rates

support
contentions
that
the
sexual
choices
of
actors
are
constrained
both

socially
and
economically.
Based
on
research,
I’m
of
the
opinion
that
poverty
will

continue
to
trump
condom
use,
and
condom
promotion
will
not
work
until
social

scientists
and
biomedical
researchers
work
together
to
factor
in
the
social

variables
of
HIV
infection.
Then,
and
only
then,
can
the
ABC
approach
be

proposed
as
a
viable
solution
to
HIV
prevention.



 32






























































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