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The perspectives of heterosexual males who have large sexual networks comprising concurrent sexual partners and who engage in high-risk sexual behaviours are scarcely documented. Yet these perspectives are crucial to understanding the high HIV prevalence in South Africa where domestic violence, sexual assault and rape are alarmingly high, suggesting problematic gender dynamics.
To explore the construction of masculinities and men's perceptions of women and their sexual relationships, among men with large sexual networks and concurrent partners.
This qualitative study was conducted in conjunction with a larger quantitative survey among men at high risk of HIV, using respondent-driven sampling to recruit participants, where long referral chains allowed us to reach far into social networks. Twenty in-depth, open-ended interviews with South African men who had multiple and concurrent sexual partners were conducted. A latent content analysis was used to explore the characteristics and dynamics of social and sexual relationships.
We found dominant masculine ideals characterised by overt economic power and multiple sexual partners. Reasons for large concurrent sexual networks were the perception that women were too empowered, could not be trusted, and lack of control over women. Existing masculine norms encourage concurrent sexual networks, ignoring the high risk of HIV transmission. Biological explanations and determinism further reinforced strong and negative perceptions of women and female sexuality, which helped polarise men's interpretation of gender constructions.
Our results highlight the need to address sexuality and gender dynamics among men in growing, informal urban areas where HIV prevalence is strikingly high. Traditional structures that could work as focal entry points should be explored for effective HIV prevention aimed at normative change among hard-to-reach men in high-risk urban and largely informal contexts.
In South Africa, an estimated 5.5 million people are living with HIV and the epidemic is not showing any convincing signs of abating. Among those infected, the highest HIV prevalence is found in urban informal environments (17.6%) compared to urban formal (9.1%), rural formal (9.9%) and rural informal (11.6%) environments (1). These urban informal settings are characterised by economic hardship and rapid societal changes that put men (and women) at increased risk of poor health outcomes (2). In addition, domestic violence, sexual assault and rape are also alarmingly high, suggesting problematic gender dynamics (3, 4).
Despite several legislative and policy changes that have been undertaken in the area of reproductive health since 1994, the outcomes of HIV behavioural interventions have largely been inadequate and ineffective and HIV incidence remains unacceptably high (5, 6). In the last 25 years, HIV prevention efforts have predominantly sought to influence the individual; targeting knowledge, attitude and practices of people, whereas structural factors, e.g. socio-cultural, organisational, legal and policy aspects of the environment that impede or facilitate an individual's efforts to avoid HIV infection, have been given less attention (7). Previous research has demonstrated the usefulness of adding a cultural orientation when aiming to predict health behaviours, as the HIV epidemic needs to be tackled through more innovative approaches (8). This is especially important when addressing structural factors that affect sexual relationships and the transmission of HIV because individual autonomy is by no means culture-free and the mode of HIV transmission has to be understood within existing explanatory systems, particularly in terms of associated images, symbols and representations (9). Further, many men living in informal, urban settings are hard to reach with traditional preventive interventions, as they are alienated from many social structures and socialise mostly at local shebeens (informal, largely unregulated venues selling alcohol) where excessive drinking takes place (10), another risk factor for sexually transmitted HIV (11).
South Africa with its history in colonial, post-colonial and apartheid eras has undergone rapid social and political changes that have promoted a highly complex mix of gender identities (12, 13). Therefore, the socio-cultural construction of sexuality in specific social contexts is key to the interpretation of planned interventions, and gender is also an integral part of the analysis as it works in an interwoven theoretical and practical manner and is essential in HIV programme design and prevention efforts. Beyond the physical determinants of sex, the term gender is more commonly defined as the deeply rooted, socio-culturally constructed expectations of women and men that influence their behaviours and opportunities in society. Contemporary gender research does not focus primarily on men and women, but rather on how womanliness and manliness is constructed as unequal categories, especially where the (unequal) distribution of material resources and power is of central importance. From this perspective, the construction of gender is linked to societal processes involving class, age, sexuality, ethnicity and more. Thus, gender can be self-defined, ascribed or imposed, and influences behaviours and opportunities in various social contexts, such as schools, workplaces, families and health systems, affecting human health and well-being (14). As a result, the constructions of gender vary in different contexts, and HIV transmission has to be understood within existing explanatory systems, particularly in terms of associated images and symbols (9). These gender structures profoundly influence an individual's sexuality, where gender dynamics play a key role in determining many aspects of a person's risk and response to HIV. These risks include an individual's vulnerability to infection, perceived risk and actual risk-taking behaviour, differential exposure to HIV, knowledge and access to health information, health-seeking behaviour, the utilisation of services for treatment and the ability to cope when infected or affected by HIV. Despite a strong emphasis on gender inequality in relation to HIV in the global health community, there are still very few programmes geared to deal effectively with gender issues (15).
Most people in the current study's context are of Xhosa origin where male sexual socialisation via initiation schools is of paramount importance. Historically, sexual socialisation during initiation used to involve physical testing, seclusion, metaphorical death and rebirth, and masculine fitness. Sexual instruction and guidance concerning married life commonly formed a part of the training during male initiation (16). The highly secretive practice is seen as part of a sexual socialisation process to regulate and endorse culturally accepted norms of heterosexual manhood. However, the role of the so-called circumcision schools has changed, and new meanings attached to the rituals have been introduced, resulting in a breakdown of young males sexual socialisation (16). This is even more evident in urban environments that have seen dramatic changes to many traditional mores of sexual socialisation, such as the rite of passage that transforms boys into men, that today are fragmented or have disappeared altogether (17). It is, therefore, vital to have a contextual understanding of the construction of masculinities, and the implications that different forms of masculine ideals can have on the HIV epidemic. The concept of a hegemonic masculinity, which represents a cultural ideal, suggests that different masculinities coexist, but that a particular version of masculinity predominates (13, 18). Thus, masculinity should rather be defined as masculinities that are contested, constructed and reconstructed, and are highly dependent on positions in the social structure (18). It is within the fluid masculinities that marginalised men often attempt to compensate for a subordinate status by adopting alternative forms of masculinities and associated behaviours (19). Furthermore, factors such as generation, ethnicity and class are also of vital importance in the make-up of masculine identities, demonstrating that the discourse of masculinity is a multilayered and complex process developed through history (20). People's social identity is based on aspects of their self-definition that arise from membership of particular social groups within specific contexts, which in turn affect health-related behaviours that are shaped and constrained by collectively negotiated social identities (21). Furthermore, as social actors, people employ cultural symbols and conceptual systems, linguistics and other representational systems to construct meaning to their world (22). We aimed at obtaining a better understanding of a dominant masculinity among men who have concurrent sexual partners and the implications for sexually transmitted HIV for future preventive intervention options in a peri-urban South African context.
We conducted a qualitative study during September and November 2006, in a peri-urban community on the outskirts of Cape Town, South Africa. This township emerged during the last two decades because of rapid in-migration and is today a permanent fixture of formal and informal dwellings, where many of the younger generation are born in the township, but still maintain strong bonds to the rural areas of their family origin. Generally, most people are living under very poor conditions with high unemployment rates, as well as high levels of crime, alcohol and drug use (23, 24).
This qualitative study was undertaken in conjunction with a larger quantitative survey among men at high risk of HIV. The quantitative survey employed respondent-driven sampling (RDS) to recruit participants (25). RDS is a chain-referral method that requires a pre-determined number of initial contacts and subsequent recruits to enlist a maximum of three new participants from their social network. The inclusion criteria for the quantitative survey were men older than 18 years, who had had more than one female sexual partner in the past 3 months, where at least one of these sexual partners was younger than 24 years, or 3 or more years younger than the participant. The male participants in the survey had a median age of 28.7 years. Close to 56% had some high school education and 17.2% were unemployed. The majority (94.7%) were not married.
Purposive sampling to identify individuals who were willing to participate in in-depth individual interviews was used among the participants in the quantitative study. Twenty participants were selected and asked to participate in the qualitative component while they were waiting to complete the quantitative survey. Interviews were conducted during weekends, as it was difficult to attract men to participate during the week. However, screening of the participants before the interviews was necessary to ensure that they were not under the influence of narcotics or alcohol, which is a common problem during weekends in the study setting. Each interview took approximately one and a half hours and was conducted by the first author (AR). A trained local interpreter was present during the interviews and translated the conversations into English and/or isiXhosa when necessary. All interviews were audiotaped, transcribed verbatim and cross-checked with the initial recordings to ensure the quality of the transcription. Participants were given a cellular telephone voucher worth 30 Rand (approximately US$4) as a token of appreciation. All informants gave written informed consent to be interviewed.
A thematic question guide (TQG) with open-ended questions was used during the interviews. The TQG provided a structure for the interviews while simultaneously allowing the interviewer to freely explore, probe and ask questions that would expand on or clarify particular topics. The TQG themes included sexual behaviours, social and sexual networks, masculinity and risk reduction strategies. The transcripts were analysed according to a latent content analysis suggested by Graneheim and Lundman (26). Descriptive, explicit areas of content with little attempt at interpretation were extracted first. These were examined for underlying meaning and situated in sub-themes that cut across categories. Sub-themes were then grouped into overarching themes that expressed the latent content of the transcripts. Data was discussed in detail by the research team to identify different themes for further analysis and to facilitate the uncovering of aspects of the underlying meaning, which contributed to the increased validity of the analysis.
Ethical clearance was obtained from the Health Sciences Faculty Research Ethics Committee at the University of Cape Town. All informants are anonymous in the text for protection and guaranteed anonymity. This research was funded by the Swedish Research Council, the Swedish International Development Agency (SIDA)/SAREC and the National Research Foundation (NRF), South Africa.
Self-perceived social identities among hard-to-reach men in the study's informal urban context suggested dominant masculine ideals and ways to legitimise specific behaviours that created a high-risk environment for sexually transmitted HIV. One common category among the study participants described reasons for having multiple, female sexual partners. Themes that emerged and that promoted power imbalances in sexual relationships were lack of trust in women, disempowerment and biological determinism.
The predominant ideal male identity was conceptualised in one word, the player, characterised by two symbols of status: wealth and women. Thus, the player incorporated symbols believed to be important in the make-up of a hegemonic masculinity and clearly helped these men to position themselves in the community. Money and material goods that could be visualised was crucial and seemed to override other status symbols such as education or societal position.
It is because these guys have a lot of money and they can afford things … Yes, and if you have money, you are the king.
You must be well dressed and you must look brand new everyday even if your clothes are not new, and you must always have money and when she asks for something sometime, you must be able to take care of that.
Symbols such as cellular telephones, sunglasses and trendy clothes were important in overtly portraying economic status, and were used to position these men in relation to other men in the study context. In this manner, new and fashionable items became important in communication with other men and were key to forming hierarchical systems that incorporated specific forms of ideal masculinities.
These symbols of material wealth also played an important role in men's strategies to access sexual networks and sexual partners. Besides displays of overt economic status, a player would be expected to show he could afford and handle several women at the same time. Women were identified as a key attribute of the dominant masculine ideal. Having multiple, often young female sexual partners further enhanced men's social position and women served as a marker of both sexual and financial power.
I can make an example about me because I have about eight girlfriends. It is my style and what I wear, my clothes and my money, because I have money.
Yes I can say that these guys are looked upon, even when ladies see that you like girls and have a lot of girls and you have friends who are girls. They will bring you more girls even if they know that you have many girls already.
Seemingly, women responded to these strategies and aided in the socialisation of men's sexual identities, with new gender power dynamics contrary to many of the previous norms in traditional initiation schools. Furthermore, strong peer pressure to have many concurrent, young sexual partners played an important part in the creation of the masculine ideal within male social groups, manifesting in large sexual networks.
I will take a lot of pressure from the boys. They will tease and make funny jokes and tell me that having one girlfriend is the same as having no one at all.
Other people will think that you do not have a game (if not having multiple girlfriends). You do not know how to treat the girls.
Within peer groups, the pressure to live up to set norms further reinforced the meaning and status of the player. If a man adopted an alternative form of masculine ideal, he would risk being emasculated and thought not to have what it takes to be a real man according to prevalent norms in this specific context and group of men. It would seem that the masculinity norms that have evolved in the study context are making use of new symbols to express power that facilitate the redefinition of men in relation to other men thereby reinforcing risky sexual behaviours. The attributes suggested for a successful man also indicate that the representations of a man, like the player, exist and are integrated into a new urban form of masculinity. To explore forms of identities, underlying and associated reasons on different levels are needed to further explain why certain types of masculinity evolve. Two themes closely associated with the player were biological determinism and frustration over a self-perceived disempowerment.
The construction of the ‘player’ not only involved the manifestation of material wealth and multiple girlfriends, but also offered a set of underlying reasons for gender-related power structures. Irrespective of whether women had long-term concurrent or temporary sexual encounters, strong and negative views about them were revealed. A woman who crossed the strict boundaries that existed for gender relations was often labelled a ‘bitch’; a term also sometimes used to describe women in general.
They get a negative label, they are called bitches. They lose their respect and dignity.
They look at them in a funny way. They call them bitches, it is a girl who is always sleeping with different partners, this is the girl I always have sex with, a girl that I use.
By assessing women's behaviour and what was perceived as unacceptable, men automatically felt that they had certain rights, which further legitimised a negative power play between men and women. Applying restrictive social norms to certain female behaviours was not the only way to define men's masculinity and to promote power imbalances. Women were also considered physically vulnerable when engaging in sexual intercourse, especially with several sexual partners. Biological determinism legitimised sexual risk taking among men, such as men having a greater need for several sexual partners, and being built for sexual encounters.
The thing is that you have lots of girls, you finish the girls, but the girl who has many boys is stupid because she is the one who is being finished.
It is because of our different sexual orientation where guys deposit and ladies receive. Because this, (the vagina), looks like a rubbish can where we throw everything in it.
Because the girl's body is destroyed pretty easy when she has a lot of men, and the guy's body does not deteriorate that easy with many girlfriends.
These biological explanations further reinforced strong, negative perceptions of women and female sexuality, which helped polarise men's interpretation of gender constructions. The fact that women often challenged predominant gender stereotypes, by engaging in what was perceived to be normative male sexual behaviour, was used as an excuse for degrading attitudes and behaviours towards women. This could explain the ‘rubbish can’ metaphor used for the vagina, and men's association of women as being ‘destroyed’ or ‘finished’ if they had multiple sexual partners. Thus, behaviours and the biology of women were themes that helped men to structure relations with women, which also promoted high-risk sexual behaviours in the form of multiple and concurrent sexual relations.
Another theme that occurred was that of an underlying frustration among these men that also reflected their position in society at large. The informants did not view ‘bitches’ or women as passive victims, but rather as active agents who strategically played their cards. This was linked to the notion that men felt disempowered in relation to women. Thus, a certain ambivalence was revealed in men's views of women and the opposition between sexes.
They are players like us because we think we play them and they are playing also their cards, they are playing us also.
They (women) got so much power now. We got less power. […] Because the women rights are too much.
This underlying distress and insecurity among these men can be seen as a sign of a situation where the traditional hegemonic masculinity is contested, allowing new forms to evolve to maintain a certain power (im)balance. The urban context characterised by lack of money and men's self-perceived disempowerment in relation to women (and society in general), created a situation where manhood was constantly questioned. Many of the men believed that women actively engaged in concurrent transactional relationships for economic benefits. This interpretation of women as active agents in relationships created a deeply rooted insecurity among men that alienated them from women. The commonly expressed negative perceptions of women were thus multilayered and reflected an intricate power play that included lack of control and distrust towards women.
According to me … all my friends actually. They cannot keep one partner anymore because they don't trust, that is why they are going around.
They are also players, because the thing is unemployment rate, if that can be organized to get jobs, maybe they can start their lives themselves. Now I know that they depend on me. If I do not give you money they will go to the next person.
Men's distrust and a perceived disempowerment in relation to women supported the formation of large sexual networks characterised by unequal power dynamics. Sexual relationships within these networks were often based on direct economic reciprocity, which is common in urban and peri-urban townships where people struggle to meet basic needs.
We found challenges to HIV prevention among men living in an urban South African township that urgently need to be addressed. The dominant masculine ideal, the ‘player’, thrived on money, multiple concurrent sexual relations and casual sex. Strong social pressure within male core groups to pursue and maintain these concurrent sexual relationships and temporary sexual encounters existed, and helped legitimise specific behaviours that the player represented. The common use of derogatory words attributed to women or their genitals, such as ‘bitch’ and ‘rubbish can’, dehumanised women and restricted female sexuality in order to retain, and in some instances, reclaim male superiority. Women were perceived as too empowered and could not be trusted, making men feel alienated and lacking control in (sexual) relationships. The lack of trust in women's fidelity was stated as an important reason for engaging in concurrent sexual relationships as well as casual sexual encounters, which is known to be a key driver of HIV transmission (10). Our findings thus support previous research showing that dominant masculinities can be characterised by large sexual networks as a means to express manhood and as a response to societal changes, unemployment and poverty, low self-esteem and perceived disempowerment (27).
The representation of a man and his associated attributes has evolved and been re-shaped into new sets of meanings, where traditional social expectations of conservative, restrained sexuality have largely changed. In this particular context, the ways in which manhood is defined has clearly put men and women at increased risk for sexually transmitted HIV as these gender structures profoundly influence men's sexual identity, and how sexuality is used to manifest power, not least between men themselves. An urban and modern way of sexual socialisation that incorporates an ideal masculinity as the player, poses a clear risk that needs to be addressed.
One potential way in which this risk could be addressed is during traditional initiation rituals that are key to the sexual socialisation of boys into men. The practice continues to be an important part of many young men's transition to adulthood and should thus be revisited for its potential in integrating gender-related HIV prevention. Previous research and designed interventions show weak support for the scaling up of traditional male circumcision as a biomedical intervention (28), but that medical circumcision together with traditional initiation could be promising (29). In the global debate, the potential benefits of circumcision in relation to HIV infection has largely had a biomedical focus, thereby ignoring the very important core of traditions and the context in which it is stipulated. By taking into account the traditional importance of rites of passage, the power of a successful intervention might not be solely in the removal of the foreskin, but rather in the development of structures in which boys can be sexually and gender socialised into responsible men. The potential in bridging traditional systems with medical interventions has shown promising results and is currently recommended (30). However, further research is required to examine the effectiveness of bridging medical and traditional interventions as well as to assess potential harm reduction associated with, for example, circumcision (28). Traditional structures could be one such entry point as they are important and give meaning to people.
This research was based on a selected group of men at high risk of sexually transmitted HIV in one specific urban environment in South Africa. Self-reported data does not fully explore underlying structures of social norms. However, these in-depth interviews gave the interviewees an opportunity to describe the quality of their social and sexual relationships and shed light on the normative systems that legitimise their behaviours in this peri-urban settlement. These norms represent a masculine ideal supported by males and accepted in society at large. This was a unique study in terms of the high-risk context in which it was conducted, and we believe we managed to reach males who are normally difficult to research, but whose behaviours are key to explaining the extremely high HIV prevalence in South African townships. Although findings might only be representative of this group of men, we believe that this unique opportunity to reach men in this harsh urban setting provides important new knowledge on how contemporary masculine ideals affect gender dynamics that need to be addressed in HIV prevention.
Our results highlight the need to more firmly address sexuality and gender dynamics among men in the growing informal urban areas with strikingly high HIV prevalence in South Africa. An understanding of a dominant urban masculinity and how key characteristics of that masculinity affect HIV transmission, as well as more innovative interventions that can help endorse alternative norms and behaviours is urgently needed. Traditional and new structures might potentially serve as focal entry points for future preventive actions, where prevention efforts should focus on changing underlying masculine ideals and gender relations that promote and maintain concurrent and temporary sexual relationships as well as other high-risk behaviours. Future research should try to explore the potential for using traditional structures in intervention strategies by testing innovative intervention models.
The authors have not received any funding or benefits from industry to conduct this study.