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Health Psychol. Author manuscript; available in PMC 2017 July 01. Published in final edited form as: Health Psychol. 2016 July ; 35(7): 751–760. doi:10.1037/hea0000351.
Partner violence, power and gender differences in South African adolescents’ HIV/STI behaviors Anne M. TEITELMAN1, John B. JEMMOTT III2,3, Scarlett L. BELLAMY2, Larry D. ICARD4, Ann O'LEARY5, G. Anita HEEREN3, Zolani NGWANE6, and Sarah J. RATCLIFFE2
Author Manuscript
1University
of Pennsylvania School of Nursing, Philadelphia, United States
2University
of Pennsylvania Perelman School of Medicine, Philadelphia, United States
3University
of Pennsylvania Annenberg School for Communication Philadelphia, United States
4Temple
University, Philadelphia, United States
5Centers
for Disease Control & Prevention, Atlanta, United States
6Haverford
College, Haverford, United States
Abstract
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Objectives—Low relationship power and victimization by intimate partner violence (IPV) have been linked to HIV risks among adult females and adolescent girls. This article examines associations of IPV and relationship power with sexual-risk behaviors and whether the associations differ by gender among South African adolescents. Methods—Sexual-risk behaviors (multiple partners in past 3 months; condom use at last sex), IPV, and relationship power were collected from 786 sexually experienced adolescents (mean age = 16.9) in Eastern Cape Province, South Africa during the 54-month follow-up of a HIV/STI riskreduction intervention trial. Logistic regression examined associations of sexual-risk behaviors with IPV and relationship power and whether the associations differed by gender.
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Results—Adolescent boys were less likely to report condom use at last sex (p=.001) and more likely to report multiple partners (p< .001). A Gender x IPV interaction (p=.002) revealed that as IPV victimization increased, self-reported condom use at last sex decreased among girls, but increased among boys. A Gender x Relationship Power interaction (p=.004) indicated that as relationship power increased, self-reported condom use at last sex increased among girls, but decreased among boys. A Gender x IPV interaction (p=.004) indicated that as IPV victimization increased, self-reports of having multiple partners increased among boys, but not among girls. As
Corresponding Author: Anne M. Teitelman, PhD, CRNP, FAANP, FAAN. School of Nursing, University of Pennsylvania. 418 Curie Blvd. Philadelphia, PA 10104. ([email protected]) Phone: 215-898-1910. Fax: 215-746-3374. Role of the Sponsors: The National Institute of Mental Health and the National Institute of Allergy and Infectious Diseases had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript. Disclaimer: The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. Additional Contributions: We appreciate the contributions of Craig Carty, MS, Janet Hsu, BA, Loretta S. Jemmott, PhD, Pretty Ndyebi, BA, Lulama Sidloyi, BA, and Joanne C. Tyler, ScD, without which this research would not have been possible.
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relationship power increased, self-reports of having multiple partners decreased irrespective of gender. Conclusions—HIV risk-reduction interventions and policies should address gender differences in sexual-risk consequences of IPV and relationship power among adolescents and promote gender equity. Keywords HIV; Africa; Condoms; Risk Factors; Sexual behavior; Adolescent; Partner abuse
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According to the 2012 Global AIDS Response Progress Report for South Africa, the prevalence of HIV among people aged 15–24 years in 2008 was 8.6% overall, with pronounced gender differences in prevalence between adolescent boys and girls, 3.6% and 13.6% respectively (Republic of South Africa, 2012). Several studies have linked victimization by intimate partner violence (IPV) to risk of HIV and other sexually transmitted infections (STI) (Decker et al., 2009; Decker, Silverman, & Raj, 2005; Jewkes, Dunkle, Nduna, & Shai, 2010; Sareen, Pagura, & Grant, 2009; Silverman, Raj, & Clements, 2004; Teitelman, Ratcliffe, Dichter, & Sullivan, 2008; Wingood & DiClemente, 1997). This link is especially important in South Africa, where the prevalence of both HIV and IPV is high and relationship power is inequitable, with men having more power than women (Jewkes & Morrell, 2010). IPV has been associated with a 12% increased risk of HIV among women in both South Africa and the United States(Jewkes, et al., 2010; Sareen, et al., 2009). Likewise, limited relationship power has been associated with greater HIV risk among adult and adolescent women (Jewkes, et al., 2010; Pulerwitz, 2000; Teitelman, Ratcliffe, Morales-Aleman, & Sullivan, 2008). For instance, in a longitudinal study, adolescent and young adult women who reported IPV victimization or lower relationship power were significantly more likely to become infected with HIV (Jewkes, et al., 2010).
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There are a number of possible mechanisms for these associations. First, women who experience violence in their relationships may be afraid to ask their partners to use condoms for fear that the request may trigger a violent reaction (Neighbors & O'Leary, 2003; Wingood & DiClemente, 1997). Second, men who perpetrate IPV may be more likely to have HIV or another STI (Decker, et al., 2009; Jewkes, et al., 2010). Third, abuse of alcohol and other drugs may lead to both IPV and risky sex (Ehrhardt, Sawires, McGovern, Peacock, & Weston, 2009; El-Bassel, Gilbert, Witte, Wu, & Chang, 2011; Kalichman et al., 2006). Fourth, emotional manipulation and threats by male partners can discourage condom use, especially in the context of inequitable power dynamics in the relationship (Teitelman, Tennille, Bohinski, Jemmott, & Jemmott, 2011). Further, it is well documented that men who are violent with their partners engage in risky sexual behavior with other partners as well as their main partner (Decker, et al., 2005; Silverman, et al., 2004). Research suggests that sexual coercion and power inequities heighten South African adolescent girls’ risk for HIV and other STIs and may increase adolescent boys’ risk as well. In a study of 15–24 year olds, coital debut before age 15 was associated with having an older partner and lack of condom use at last sex in both adolescent girls and boys and in boys, forced sex was also linked with a lack of condom use at first sex (Pettifor, O'Brien,
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Macphail, Miller, & Rees, 2009). Among adolescent girls ages 15–19, having a male partners >5 years older has been associated with an increased risk of HIV (Pettifor et al., 2005). It has been reported that approximately 40% of adolescent girls ages 15–24 were not willing the first time they had sex compared with 3–4% of adolescent boys (Pettifor, et al., 2009).
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The landscape of gender-based sexual norms in South Africa, a manifestation of the social construction of masculinities and femininities, is important for understanding gender inequities and associated sexual risks faced by adolescents. The prevalent gender-based sexual norms in South Africa discourage adolescent girls from being forthright about their sexual interests and taking charge of their sexuality (Jewkes & Morrell, 2010) and accord greater status to adolescent males for being sexually active and aggressive. As a result, adolescent males often perceive girls’ sexual reluctance as an invitation to pursue them sexually. These incongruent dynamics of sexual communication make it challenging for adolescent girls to accurately convey their interests or lack thereof and for adolescent boys to accurately ascertain cues for continued pursuit (Varga, 2003). Girls often have older male partners which increases gender power imbalances (Wingood & DiClemente, 2002). Furthermore, condom use is hampered by its association with infidelity, which carries negative stigma for girls but not boys (Varga, 2003). Social norms are group perceptions about what is commonly done or what should be done within a particular reference group, and they exert influence on behavior.
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Social norms are learned in the process of socialization and held in place by several factors including internalization and sanctions that are applied for non-compliance. With strong sanctions social norms may be adhered to more rigidly and with fewer sanctions they may be more relaxed. Social norms change occurs when new ideas and practices are accepted as the standard (Bicchieri, 2015; Marcus & Harper, 2014).
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Gender norms encompass gender roles which are commonly accepted gender-associated behaviors as well as gender ideologies, which are widely-held perceptions about masculinity and femininity (Marcus & Harper, 2014). Traditional standards of masculinity and femininity are constraining for both adolescent boys and girls and deviations are enforced in relation to the rigidity of expectations. Traditional gender norms are often discriminatory in that they reinforce adolescent boys having greater decision-making power (Connell, 2014; Wingood & DiClemente, 2002). In the realm of sexual gender norms in heterosexual relationships, for example, greater power ascribed to adolescent boys allows them to insist on sex including sex without a condom and makes is difficult for girls to refuse should they refuse, they may face sanctions such as rejection or partner violence. However, adolescent boys are encouraged to take more risks, pay less attention to their health, and have more sexual partners than girls and these patterns contribute to HIV risk (Ehrhardt, et al., 2009). The onset of sexual behaviors in adolescence is a key moment in the socialization of gender norms that reflect existing power relations between boys and girls and also offers an opportunity for change. Adolescent girls and boys report similar rates of experiencing physical partner violence in the U.S. at approximately 10– 40% (Foshee, 1996; O'Keefe & Treister, 1998; Spencer &
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Bryant, 2000). In contrast, adolescent girls report higher rates of sexual victimization, psychological abuse, and severe injuries than do adolescent boys (Foshee, 1996; Spencer & Bryant, 2000). Studies in both the U.S. and South Africa indicate adolescent girls equally perpetrate or are more likely to perpetrate partner physical violence (Flisher, Myer, Merais, Lombard, & Reddy, 2007; Howard, Qiu, & Boekeloo, 2003; Spencer & Bryant, 2000), but are more likely to be motivated by self-defense compared with adolescent boys (Foshee, 1996; O'Keefe & Treister, 1998). Thus, the motivation and consequences of adolescent IPV may vary by gender. These gender differences in IPV experiences, in light of the genderbased sexual norms in South Africa, suggest that IPV experienced by boys may be the result of self-defense on the part of girls in response to partner aggression.
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There are many ways to operationalize IPV, including physical, sexual, threatening, and psychological IPV, and all may be related to sexual risk (Teitelman, Ratcliffe, Dichter, et al., 2008). Also, when boys have more power in a relationship than girls, they are likely to have more influence over decisions that affect them both, which is especially pertinent in situations when the girl’s choices about her sexual safety are different than her partner’s (Teitelman, et al., 2011). These associations have been demonstrated among adolescent girls and young adult women in South Africa (Jewkes, et al., 2010) and adolescent girls in the U.S. (Teitelman, Ratcliffe, Morales-Aleman, et al., 2008). However, relationship power may be perceived differently for adolescent boys than girls, given that dominant gender-based norms favor adolescent boys’ decision-making power in sexual situations. To our knowledge, no studies have examined the associations of IPV and relationship power to sexual-risk behaviors or the various types of IPV among South African adolescent boys and girls. Therefore, the purpose of this study is to determine if there are gender differences in the associations between IPV/relationship power and sexual risk behaviors (condom use at last sex and multiple partners).
Author Manuscript
Our examination of IPV and sexual relationship power by gender may provide insight about social norms in this population. This understanding is needed to enhance the impact of HIV prevention strategies for adolescents and to promote safe interactions in relationships. Accordingly, this study uses 54-month follow-up data from a sexual risk-reduction intervention trial conducted in Eastern Cape Province, South Africa with sixth-grade adolescents (J. B. Jemmott, 3rd et al., 2010; J. B. Jemmott, 3rd, & Jemmott, 2015).
Methods Study Design
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Between 2004 and 2005, grade 6 students from 18 schools in Eastern Cape Province, South Africa were enrolled in a cluster-randomized controlled trial to test the efficacy of a schoolbased HIV/STI risk-reduction intervention. The Institutional Review Board at the University of Pennsylvania and the ethic committee of the collaborating University of Fort Hare approved the study. Information about the procedures, recruitment, consent, interventions, and findings of the trial has been previously reported (J. B. Jemmott, 3rd, et al., 2010; J. B. Jemmott, 3rd, & Jemmott, 2015). Briefly, schools were randomized to a HIV/STI riskreduction intervention or a health-promotion control intervention. Written consent from parent or guardian and assent from students were required for participation. The intervention Health Psychol. Author manuscript; available in PMC 2017 July 01.
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and all assessments were conducted in Xhosa. Students completed paper and pencil questionnaires, with the questions read aloud by data collectors bilingual in Xhosa and English, before receiving an intervention, immediately post-intervention, and 3, 6 12, 24, 36, 48 and 54 months post-intervention. This article draws from the 54-month follow-up assessment. It analyzes data from the students attending the 54-month follow-up who reported sexual debut. Measures
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Sexual risk outcome variables—We assessed two behaviors associated with the risk of STI, condom use at last sex and having multiple sexual partners in the prior 3 months. Condom use at last sex was assessed with the question, “The last time you had vaginal intercourse, was a condom used?” Participants’ responses were coded “1” if they did not use a condom and “2” if they used a condom. Vaginal intercourse was defined as “penis in vagina”. Having multiple partners was assessed using the question, “In the past 3 months how many [for girls: male/for boys: female] have you had vaginal intercourse with?” As described elsewhere (J. B. Jemmott, 3rd, et al., 2010; J. B. Jemmott, 3rd, & Jemmott, 2015), participants’ responses were coded “1” if they had 0 or 1 partners and “2” if they had 2 or more partners, consistent with several sexual risk reduction studies (Jennings, Glass, Parham, Adler, & Ellen, 2004; Tanser et al., 2011; Vasilenko & Lanza, 2014; Zhang, Jemmott, & Jemmott, In Press)
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Intimate partner violence (IPV)—We assessed IPV with an adapted version of the Conflict in Adolescent Dating Relationship Inventory (Wolfe, 2001). The introduction to the scale referenced, “ … things that may have happened to you with a sexual partner while you were having an argument… in the past year”. We used the 22-item total IPV scale (Cronbach’s alpha in our sample = .91) comprised of 4 subscales: physical IPV (4 items, alpha = .80), threatening IPV (4 items, alpha = .75), psychological IPV (10 items, alpha = . 84), and sexual IPV (4 items, alpha = .79). The score on each was the sum of the items comprising it. All items were rated on 7-point scales from 0 to 6 or more with a possible range of 0 – 132.
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Relationship power—To measure relationship power, we used an adapted version of the Sexual Relationship Power Scale (SRPS) (Pulerwitz, 2000). The original SRPS contained 23 items and consisted of two subscales. We used all 8 items in the Decision-making Dominance subscale. We did not use the 3 condom-related items and 1 multiple partnerrelated item in the Relationship Control subscale to avoid artificially inflated correlations between relationship power and the two outcome variables of condom use and multiple partners. We did not use 4 additional items because they did not seem to be clear indicators of relationship control for adolescents in South Africa. We used a 4-point disagree/agree Likert scale response set. The score was the sum of the responses to the 15 items (alpha = . 90) with a possible range of 15 – 60. Demographic and health variables—Demographic and health variables included age, alcohol use in past 30 days, dagga (marijuana) use in past 30 days, whether adolescents live with their mother or their father, age at first sex, age of last sexual partner, history of
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transactional sex variables (had vaginal intercourse because given a gift; has older partner who buys things and has sex), history of experiencing forced sex, and HIV intervention (1= HIV risk reduction intervention, 0 = health promotion control intervention). Data Analysis
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Basic descriptive statistics (e.g., means +/− standard error or frequencies and percentages) at the 54-month follow-up assessment by gender are reported in Table 1, with corresponding tests of gender differences (chi-square for categorical variables and two-sample Wilcoxon tests for continuous variables). We report Pearson correlation estimates between each outcome (multiple partners in the past 90 days and condom use at last sex) and each correlate (IPV total score, IPV subscales and relationship power) in Table 2. In the primary analyses, we employed a logistic modeling approach to test whether the relation of IPV and relationship power to the sexual behavior outcomes varied by gender. Specifically, logistic regression models were fit for each binary outcome of interest, reported multiple partners in the past 90 days and condom use at last sex. Separate analyses were conducted for relationship power and each of the 5 IPV predictors. Unadjusted models included gender, the IPV or relationship power correlate, and the corresponding Gender x Correlate interaction. We also fit similar models adjusting variables that were significantly associated with gender from Table 1 (e.g., ‘gender-associated’) for both outcomes. Finally, for the multiple partners in the past 90 days outcome, we fit the unadjusted model to include the multiple partners at baseline; there were too few sexually active adolescents at baseline to fit a corresponding series of models for the ‘condom use at last sex’ outcome. These models are summarized in Table 3. Significant gender differences in the relation of the correlate to each outcome were indicated when the Gender x Correlate interaction term was statistically significant. When summarizing the findings, because the IPV total score, its subscales, and the relationship power measure are all continuous variables, in addition to providing the omnibus test statistic and corresponding p-value for the Gender x Correlate interaction, we summarize the results graphically by presenting scatterplots of the predicted probability of each primary outcome for boys and girls using estimates derived from the corresponding fitted model (Figure 1).
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Results
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Of the 1,057 students enrolled in the trial, 977 or 92.4% were retained at the 54-month follow-up. Attending the 54-month follow-up was unrelated to sex, father’s presence in the household, residing in the semi-rural area, or sexual behavior at baseline ps > .32. However, only 146 (83.3%) of learners ages 14–18 years at baseline returned for a follow-up compared with 591 (93.2%) of those ages 12–13 and 240 (96.8%) of those ages 9–11, χ2 (2, 1057) = 27.52, p < .0001. Table 1 summarizes demographic variables by gender of the sample for the present analyses, the 786 adolescents, 377 girls and 409 boys, attending the 54-month follow-up who reported sexual debut. Compared with girls, boys reported significantly more alcohol and dagga use in the past 30 days, were older, reported having fewer partners > 5 years older, were more likely to report having first sexual encounters before age 13, and were less likely to report exchanging sex for a beer, gift, meal or lift or having an older partner who buys them things and has sex with them. Additionally,
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compared with girls, boys were more likely to report histories of forcing someone to have sex, had lower relationship power scores, were less likely to report condom use at last sex, and were more likely to report multiple partners and same-gender sexual experiences. Overall, 83% of the participants had experienced at least one type of IPV within the past year.
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As shown in Table 2, total IPV scores were correlated with less reported condom use at last sex for girls (ρ= −0.137, ρ=0.0110), but not for boys (ρ = 0.101, ρ=0.0613). Similar correlations were observed for IPV subscales, with the exception of emotional IPV which was not correlated with condom use for boys or girls. Higher relationship power was positively correlated with condom use at last sex for girls (ρ = 0.143, ρ=0.0079), but not for boys (ρ = −0.080, ρ=0.1389). Most IPV scores (total and subscales) were not correlated with reported multiple partners in the past 90 days for girls, except the threatening IPV subscale. Specifically, higher threatening IPV subscale scores were correlated with reporting multiple partners in the past 90 days for girls (ρ = 0.106, ρ = 0.0440). Each IPV score was positively correlated with reported multiple partners in the past 90 days for boys. For example, the estimated correlation between IPV total score and multiple partners in boys was 0.292 (p
Health Psychol. Author manuscript; available in PMC 2017 July 01. Published in final edited form as: Health Psychol. 2016 July ; 35(7): 751–760. doi:10.1037/hea0000351.
Partner violence, power and gender differences in South African adolescents’ HIV/STI behaviors Anne M. TEITELMAN1, John B. JEMMOTT III2,3, Scarlett L. BELLAMY2, Larry D. ICARD4, Ann O'LEARY5, G. Anita HEEREN3, Zolani NGWANE6, and Sarah J. RATCLIFFE2
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1University
of Pennsylvania School of Nursing, Philadelphia, United States
2University
of Pennsylvania Perelman School of Medicine, Philadelphia, United States
3University
of Pennsylvania Annenberg School for Communication Philadelphia, United States
4Temple
University, Philadelphia, United States
5Centers
for Disease Control & Prevention, Atlanta, United States
6Haverford
College, Haverford, United States
Abstract
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Objectives—Low relationship power and victimization by intimate partner violence (IPV) have been linked to HIV risks among adult females and adolescent girls. This article examines associations of IPV and relationship power with sexual-risk behaviors and whether the associations differ by gender among South African adolescents. Methods—Sexual-risk behaviors (multiple partners in past 3 months; condom use at last sex), IPV, and relationship power were collected from 786 sexually experienced adolescents (mean age = 16.9) in Eastern Cape Province, South Africa during the 54-month follow-up of a HIV/STI riskreduction intervention trial. Logistic regression examined associations of sexual-risk behaviors with IPV and relationship power and whether the associations differed by gender.
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Results—Adolescent boys were less likely to report condom use at last sex (p=.001) and more likely to report multiple partners (p< .001). A Gender x IPV interaction (p=.002) revealed that as IPV victimization increased, self-reported condom use at last sex decreased among girls, but increased among boys. A Gender x Relationship Power interaction (p=.004) indicated that as relationship power increased, self-reported condom use at last sex increased among girls, but decreased among boys. A Gender x IPV interaction (p=.004) indicated that as IPV victimization increased, self-reports of having multiple partners increased among boys, but not among girls. As
Corresponding Author: Anne M. Teitelman, PhD, CRNP, FAANP, FAAN. School of Nursing, University of Pennsylvania. 418 Curie Blvd. Philadelphia, PA 10104. ([email protected]) Phone: 215-898-1910. Fax: 215-746-3374. Role of the Sponsors: The National Institute of Mental Health and the National Institute of Allergy and Infectious Diseases had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript. Disclaimer: The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. Additional Contributions: We appreciate the contributions of Craig Carty, MS, Janet Hsu, BA, Loretta S. Jemmott, PhD, Pretty Ndyebi, BA, Lulama Sidloyi, BA, and Joanne C. Tyler, ScD, without which this research would not have been possible.
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relationship power increased, self-reports of having multiple partners decreased irrespective of gender. Conclusions—HIV risk-reduction interventions and policies should address gender differences in sexual-risk consequences of IPV and relationship power among adolescents and promote gender equity. Keywords HIV; Africa; Condoms; Risk Factors; Sexual behavior; Adolescent; Partner abuse
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According to the 2012 Global AIDS Response Progress Report for South Africa, the prevalence of HIV among people aged 15–24 years in 2008 was 8.6% overall, with pronounced gender differences in prevalence between adolescent boys and girls, 3.6% and 13.6% respectively (Republic of South Africa, 2012). Several studies have linked victimization by intimate partner violence (IPV) to risk of HIV and other sexually transmitted infections (STI) (Decker et al., 2009; Decker, Silverman, & Raj, 2005; Jewkes, Dunkle, Nduna, & Shai, 2010; Sareen, Pagura, & Grant, 2009; Silverman, Raj, & Clements, 2004; Teitelman, Ratcliffe, Dichter, & Sullivan, 2008; Wingood & DiClemente, 1997). This link is especially important in South Africa, where the prevalence of both HIV and IPV is high and relationship power is inequitable, with men having more power than women (Jewkes & Morrell, 2010). IPV has been associated with a 12% increased risk of HIV among women in both South Africa and the United States(Jewkes, et al., 2010; Sareen, et al., 2009). Likewise, limited relationship power has been associated with greater HIV risk among adult and adolescent women (Jewkes, et al., 2010; Pulerwitz, 2000; Teitelman, Ratcliffe, Morales-Aleman, & Sullivan, 2008). For instance, in a longitudinal study, adolescent and young adult women who reported IPV victimization or lower relationship power were significantly more likely to become infected with HIV (Jewkes, et al., 2010).
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There are a number of possible mechanisms for these associations. First, women who experience violence in their relationships may be afraid to ask their partners to use condoms for fear that the request may trigger a violent reaction (Neighbors & O'Leary, 2003; Wingood & DiClemente, 1997). Second, men who perpetrate IPV may be more likely to have HIV or another STI (Decker, et al., 2009; Jewkes, et al., 2010). Third, abuse of alcohol and other drugs may lead to both IPV and risky sex (Ehrhardt, Sawires, McGovern, Peacock, & Weston, 2009; El-Bassel, Gilbert, Witte, Wu, & Chang, 2011; Kalichman et al., 2006). Fourth, emotional manipulation and threats by male partners can discourage condom use, especially in the context of inequitable power dynamics in the relationship (Teitelman, Tennille, Bohinski, Jemmott, & Jemmott, 2011). Further, it is well documented that men who are violent with their partners engage in risky sexual behavior with other partners as well as their main partner (Decker, et al., 2005; Silverman, et al., 2004). Research suggests that sexual coercion and power inequities heighten South African adolescent girls’ risk for HIV and other STIs and may increase adolescent boys’ risk as well. In a study of 15–24 year olds, coital debut before age 15 was associated with having an older partner and lack of condom use at last sex in both adolescent girls and boys and in boys, forced sex was also linked with a lack of condom use at first sex (Pettifor, O'Brien,
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Macphail, Miller, & Rees, 2009). Among adolescent girls ages 15–19, having a male partners >5 years older has been associated with an increased risk of HIV (Pettifor et al., 2005). It has been reported that approximately 40% of adolescent girls ages 15–24 were not willing the first time they had sex compared with 3–4% of adolescent boys (Pettifor, et al., 2009).
Author Manuscript
The landscape of gender-based sexual norms in South Africa, a manifestation of the social construction of masculinities and femininities, is important for understanding gender inequities and associated sexual risks faced by adolescents. The prevalent gender-based sexual norms in South Africa discourage adolescent girls from being forthright about their sexual interests and taking charge of their sexuality (Jewkes & Morrell, 2010) and accord greater status to adolescent males for being sexually active and aggressive. As a result, adolescent males often perceive girls’ sexual reluctance as an invitation to pursue them sexually. These incongruent dynamics of sexual communication make it challenging for adolescent girls to accurately convey their interests or lack thereof and for adolescent boys to accurately ascertain cues for continued pursuit (Varga, 2003). Girls often have older male partners which increases gender power imbalances (Wingood & DiClemente, 2002). Furthermore, condom use is hampered by its association with infidelity, which carries negative stigma for girls but not boys (Varga, 2003). Social norms are group perceptions about what is commonly done or what should be done within a particular reference group, and they exert influence on behavior.
Author Manuscript
Social norms are learned in the process of socialization and held in place by several factors including internalization and sanctions that are applied for non-compliance. With strong sanctions social norms may be adhered to more rigidly and with fewer sanctions they may be more relaxed. Social norms change occurs when new ideas and practices are accepted as the standard (Bicchieri, 2015; Marcus & Harper, 2014).
Author Manuscript
Gender norms encompass gender roles which are commonly accepted gender-associated behaviors as well as gender ideologies, which are widely-held perceptions about masculinity and femininity (Marcus & Harper, 2014). Traditional standards of masculinity and femininity are constraining for both adolescent boys and girls and deviations are enforced in relation to the rigidity of expectations. Traditional gender norms are often discriminatory in that they reinforce adolescent boys having greater decision-making power (Connell, 2014; Wingood & DiClemente, 2002). In the realm of sexual gender norms in heterosexual relationships, for example, greater power ascribed to adolescent boys allows them to insist on sex including sex without a condom and makes is difficult for girls to refuse should they refuse, they may face sanctions such as rejection or partner violence. However, adolescent boys are encouraged to take more risks, pay less attention to their health, and have more sexual partners than girls and these patterns contribute to HIV risk (Ehrhardt, et al., 2009). The onset of sexual behaviors in adolescence is a key moment in the socialization of gender norms that reflect existing power relations between boys and girls and also offers an opportunity for change. Adolescent girls and boys report similar rates of experiencing physical partner violence in the U.S. at approximately 10– 40% (Foshee, 1996; O'Keefe & Treister, 1998; Spencer &
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Bryant, 2000). In contrast, adolescent girls report higher rates of sexual victimization, psychological abuse, and severe injuries than do adolescent boys (Foshee, 1996; Spencer & Bryant, 2000). Studies in both the U.S. and South Africa indicate adolescent girls equally perpetrate or are more likely to perpetrate partner physical violence (Flisher, Myer, Merais, Lombard, & Reddy, 2007; Howard, Qiu, & Boekeloo, 2003; Spencer & Bryant, 2000), but are more likely to be motivated by self-defense compared with adolescent boys (Foshee, 1996; O'Keefe & Treister, 1998). Thus, the motivation and consequences of adolescent IPV may vary by gender. These gender differences in IPV experiences, in light of the genderbased sexual norms in South Africa, suggest that IPV experienced by boys may be the result of self-defense on the part of girls in response to partner aggression.
Author Manuscript
There are many ways to operationalize IPV, including physical, sexual, threatening, and psychological IPV, and all may be related to sexual risk (Teitelman, Ratcliffe, Dichter, et al., 2008). Also, when boys have more power in a relationship than girls, they are likely to have more influence over decisions that affect them both, which is especially pertinent in situations when the girl’s choices about her sexual safety are different than her partner’s (Teitelman, et al., 2011). These associations have been demonstrated among adolescent girls and young adult women in South Africa (Jewkes, et al., 2010) and adolescent girls in the U.S. (Teitelman, Ratcliffe, Morales-Aleman, et al., 2008). However, relationship power may be perceived differently for adolescent boys than girls, given that dominant gender-based norms favor adolescent boys’ decision-making power in sexual situations. To our knowledge, no studies have examined the associations of IPV and relationship power to sexual-risk behaviors or the various types of IPV among South African adolescent boys and girls. Therefore, the purpose of this study is to determine if there are gender differences in the associations between IPV/relationship power and sexual risk behaviors (condom use at last sex and multiple partners).
Author Manuscript
Our examination of IPV and sexual relationship power by gender may provide insight about social norms in this population. This understanding is needed to enhance the impact of HIV prevention strategies for adolescents and to promote safe interactions in relationships. Accordingly, this study uses 54-month follow-up data from a sexual risk-reduction intervention trial conducted in Eastern Cape Province, South Africa with sixth-grade adolescents (J. B. Jemmott, 3rd et al., 2010; J. B. Jemmott, 3rd, & Jemmott, 2015).
Methods Study Design
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Between 2004 and 2005, grade 6 students from 18 schools in Eastern Cape Province, South Africa were enrolled in a cluster-randomized controlled trial to test the efficacy of a schoolbased HIV/STI risk-reduction intervention. The Institutional Review Board at the University of Pennsylvania and the ethic committee of the collaborating University of Fort Hare approved the study. Information about the procedures, recruitment, consent, interventions, and findings of the trial has been previously reported (J. B. Jemmott, 3rd, et al., 2010; J. B. Jemmott, 3rd, & Jemmott, 2015). Briefly, schools were randomized to a HIV/STI riskreduction intervention or a health-promotion control intervention. Written consent from parent or guardian and assent from students were required for participation. The intervention Health Psychol. Author manuscript; available in PMC 2017 July 01.
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and all assessments were conducted in Xhosa. Students completed paper and pencil questionnaires, with the questions read aloud by data collectors bilingual in Xhosa and English, before receiving an intervention, immediately post-intervention, and 3, 6 12, 24, 36, 48 and 54 months post-intervention. This article draws from the 54-month follow-up assessment. It analyzes data from the students attending the 54-month follow-up who reported sexual debut. Measures
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Sexual risk outcome variables—We assessed two behaviors associated with the risk of STI, condom use at last sex and having multiple sexual partners in the prior 3 months. Condom use at last sex was assessed with the question, “The last time you had vaginal intercourse, was a condom used?” Participants’ responses were coded “1” if they did not use a condom and “2” if they used a condom. Vaginal intercourse was defined as “penis in vagina”. Having multiple partners was assessed using the question, “In the past 3 months how many [for girls: male/for boys: female] have you had vaginal intercourse with?” As described elsewhere (J. B. Jemmott, 3rd, et al., 2010; J. B. Jemmott, 3rd, & Jemmott, 2015), participants’ responses were coded “1” if they had 0 or 1 partners and “2” if they had 2 or more partners, consistent with several sexual risk reduction studies (Jennings, Glass, Parham, Adler, & Ellen, 2004; Tanser et al., 2011; Vasilenko & Lanza, 2014; Zhang, Jemmott, & Jemmott, In Press)
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Intimate partner violence (IPV)—We assessed IPV with an adapted version of the Conflict in Adolescent Dating Relationship Inventory (Wolfe, 2001). The introduction to the scale referenced, “ … things that may have happened to you with a sexual partner while you were having an argument… in the past year”. We used the 22-item total IPV scale (Cronbach’s alpha in our sample = .91) comprised of 4 subscales: physical IPV (4 items, alpha = .80), threatening IPV (4 items, alpha = .75), psychological IPV (10 items, alpha = . 84), and sexual IPV (4 items, alpha = .79). The score on each was the sum of the items comprising it. All items were rated on 7-point scales from 0 to 6 or more with a possible range of 0 – 132.
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Relationship power—To measure relationship power, we used an adapted version of the Sexual Relationship Power Scale (SRPS) (Pulerwitz, 2000). The original SRPS contained 23 items and consisted of two subscales. We used all 8 items in the Decision-making Dominance subscale. We did not use the 3 condom-related items and 1 multiple partnerrelated item in the Relationship Control subscale to avoid artificially inflated correlations between relationship power and the two outcome variables of condom use and multiple partners. We did not use 4 additional items because they did not seem to be clear indicators of relationship control for adolescents in South Africa. We used a 4-point disagree/agree Likert scale response set. The score was the sum of the responses to the 15 items (alpha = . 90) with a possible range of 15 – 60. Demographic and health variables—Demographic and health variables included age, alcohol use in past 30 days, dagga (marijuana) use in past 30 days, whether adolescents live with their mother or their father, age at first sex, age of last sexual partner, history of
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transactional sex variables (had vaginal intercourse because given a gift; has older partner who buys things and has sex), history of experiencing forced sex, and HIV intervention (1= HIV risk reduction intervention, 0 = health promotion control intervention). Data Analysis
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Basic descriptive statistics (e.g., means +/− standard error or frequencies and percentages) at the 54-month follow-up assessment by gender are reported in Table 1, with corresponding tests of gender differences (chi-square for categorical variables and two-sample Wilcoxon tests for continuous variables). We report Pearson correlation estimates between each outcome (multiple partners in the past 90 days and condom use at last sex) and each correlate (IPV total score, IPV subscales and relationship power) in Table 2. In the primary analyses, we employed a logistic modeling approach to test whether the relation of IPV and relationship power to the sexual behavior outcomes varied by gender. Specifically, logistic regression models were fit for each binary outcome of interest, reported multiple partners in the past 90 days and condom use at last sex. Separate analyses were conducted for relationship power and each of the 5 IPV predictors. Unadjusted models included gender, the IPV or relationship power correlate, and the corresponding Gender x Correlate interaction. We also fit similar models adjusting variables that were significantly associated with gender from Table 1 (e.g., ‘gender-associated’) for both outcomes. Finally, for the multiple partners in the past 90 days outcome, we fit the unadjusted model to include the multiple partners at baseline; there were too few sexually active adolescents at baseline to fit a corresponding series of models for the ‘condom use at last sex’ outcome. These models are summarized in Table 3. Significant gender differences in the relation of the correlate to each outcome were indicated when the Gender x Correlate interaction term was statistically significant. When summarizing the findings, because the IPV total score, its subscales, and the relationship power measure are all continuous variables, in addition to providing the omnibus test statistic and corresponding p-value for the Gender x Correlate interaction, we summarize the results graphically by presenting scatterplots of the predicted probability of each primary outcome for boys and girls using estimates derived from the corresponding fitted model (Figure 1).
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Results
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Of the 1,057 students enrolled in the trial, 977 or 92.4% were retained at the 54-month follow-up. Attending the 54-month follow-up was unrelated to sex, father’s presence in the household, residing in the semi-rural area, or sexual behavior at baseline ps > .32. However, only 146 (83.3%) of learners ages 14–18 years at baseline returned for a follow-up compared with 591 (93.2%) of those ages 12–13 and 240 (96.8%) of those ages 9–11, χ2 (2, 1057) = 27.52, p < .0001. Table 1 summarizes demographic variables by gender of the sample for the present analyses, the 786 adolescents, 377 girls and 409 boys, attending the 54-month follow-up who reported sexual debut. Compared with girls, boys reported significantly more alcohol and dagga use in the past 30 days, were older, reported having fewer partners > 5 years older, were more likely to report having first sexual encounters before age 13, and were less likely to report exchanging sex for a beer, gift, meal or lift or having an older partner who buys them things and has sex with them. Additionally,
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compared with girls, boys were more likely to report histories of forcing someone to have sex, had lower relationship power scores, were less likely to report condom use at last sex, and were more likely to report multiple partners and same-gender sexual experiences. Overall, 83% of the participants had experienced at least one type of IPV within the past year.
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As shown in Table 2, total IPV scores were correlated with less reported condom use at last sex for girls (ρ= −0.137, ρ=0.0110), but not for boys (ρ = 0.101, ρ=0.0613). Similar correlations were observed for IPV subscales, with the exception of emotional IPV which was not correlated with condom use for boys or girls. Higher relationship power was positively correlated with condom use at last sex for girls (ρ = 0.143, ρ=0.0079), but not for boys (ρ = −0.080, ρ=0.1389). Most IPV scores (total and subscales) were not correlated with reported multiple partners in the past 90 days for girls, except the threatening IPV subscale. Specifically, higher threatening IPV subscale scores were correlated with reporting multiple partners in the past 90 days for girls (ρ = 0.106, ρ = 0.0440). Each IPV score was positively correlated with reported multiple partners in the past 90 days for boys. For example, the estimated correlation between IPV total score and multiple partners in boys was 0.292 (p
