Research brief: A case study on rights, values and services in Pietermaritzburg, South Africa

Author: Mzikazi Nduna (Wits University) Editors: Deborah Ewing, Jane Argall

AIDS Foundation of South Africa July 2017 ACKNOWLEDGEMENTS I would like to thank Thulile Louisa Mbhele and Moeti Lesuthu of the AIDS Foundation of South Africa (AFSA) for supporting the implementation of this study. Thanks are also due to research coordinator Maxwell Magobolo and his team of field workers, and to all the research participants who provided valuable information and gave freely of their time.

I would also like to thank colleagues from Department of Psychology at the University of the Witwatersrand: Dr Peace Kiguwa; Lesego Ndhlovu; Nosiphe Mxoli; Matamela Makongoza, Oncemore Mbeve and Andile Mthombeni, for their contributions to the report and their participation in the member-checking meeting in Pietermaritzburg. The researchers’ writing of this series of reports was made possible by support from the National Research Foundation Centre of Excellence (COE-HUMAN), the Faculty of Humanities at WITS and AIDS Accountability International, through a Ford Foundation grant.

AFSA’s Sexual and Reproductive Health Rights (SRHR) Programme, for which this study was undertaken, is supported by the Embassy of Sweden and the Norwegian Aid Agency Norad.

Photos: GLN Contents

ACRONYMS 4 1. INTRODUCTION 5

2. STUDY DESIGN 7

3. FINDINGS 8

Relationship dynamics 8 Family planning, pregnancy and abortion 10 STIs and HIV/AIDS 20 Access to health services 22 Parenting and SRHR 23 Sexual orientation and gender identity (SOGI) (LGBTI) 30

4. CONCLUSIONS 35

5. RECOMMENDATIONS 36

SRHR education 36 Parent-child communication (PCC) 36 Challenging stigma, stereotypes and social behaviour 36 Access to contraceptives 36

6. REFERENCES 37

RESEARCH BRIEF 2 | JULY 2017 3 ACRONYMS

CBO Community based organisation CSG Child Support Grant cToP Choice of Termination of Pregnancy DoH Department of Health FGD Focused Group Discussion HSRC Human Science Research Council KI Key Informant KII Key Informant Interview KRCC KwaZulu-Natal Regional Council of Churches KZN KwaZulu-Natal NGO Non-government organisation SGB School Governing Body SOGI Sexual Orientation and Gender Identity SRH Sexual and Reproductive Health SRHR Sexual and Reproductive Health Rights STI Sexually transmitted infection VMMC Voluntary Medical Male Circumcision

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4 RESEARCH BRIEF 2 | JULY 2017 1. INTRODUCTION Cultural beliefs and systems are transferable The case study presented here is the second in a from generation to generation, but are not static series of reports from a study undertaken as part because cultures change over time in response to of an ongoing research programme to explore the altered circumstances and environments. African alignment of traditional belief systems with sexual cultures are known to be mostly collectivist, with and reproductive health and rights (SRHR) in language being the core indicator of cultural South Africa. The purpose of this research is to identity and cultural interdependence (Eaton & provide evidence of the positive and negative Louw, 2000). influences of culture, religion and traditional practices on men and women’s access to SRHR, In different ways, sexual and reproductive health and to inform effective community interventions, outcomes are influenced by, among other particularly with women, young people and variables, culture. Traditional and conservative sexual minorities. beliefs attributed to certain groups of people are reported to influence access and utilisation of health Culture is the way of life of a group of people, and prevention messages (Nduna & Mendes, 2010). is seen in the way people behave, dress, how they relate to those within and outside of their group, In South Africa, there are various traditions and their values and belief systems. Another practised in line with the diversity of cultures. definition refers to culture as a set of dynamic According to the Oxford dictionary (2015), beliefs and practices introduced with internal tradition is defined as “… the transmission of ambiguities and contradictions, albeit often customs or beliefs from generation to generation, reduced to static traditions that were practised in or the fact of being passed on in this way”. the past (Shope, 2006). Among African communities, tradition can also be

RESEARCH BRIEF 2 | JULY 2017 5 regarded as a cultural practice that refers to the In this study we were interested in examining the way of honouring the elders and the community, role that religion and culture plays in facilitating and which needs to be adhered to by members or hindering SRHR access. The views of the four of a particular community (Heeren, Jemmott, participating Pietermaritzburg communities aim to Tyler, Tshabe, & Ngwane, 2011). Traditions are provide valuable baseline data needed to assess regularly linked to SRHR outcomes in research the influence of SRHR outreach interventions that (George, 2008). are delivered by the Gay and Lesbian Network, an AFSA-supported non-government organisation in Culture and religion have particular values and the greater Pietermaritzburg area. rituals. Religion is defined by characteristics that include a strong belief in a supreme being, Shortly after the data were collected, KwaZulu- a belief in spirits and divinities, and a sense of Natal, and Pietermaritzburg in particular, made community among those who follow a particular headlines because a woman tried to sell a baby religious path (Beyers, 2010). A religious practice on the Gumtree website. Mothers abandoning expresses the deepest values that a particular babies is reported in the media to be a ‘huge person chooses to be guided by. It refers to one’s problem’. The response is usually condemnation of faith and faith-based practice. Faith can be an the woman concerned. However, cases like these intensely political act (Welty, 2005). It can be an also reflect the fact that services and support are individualised practice that shapes action and is urgently needed to prevent unwanted pregnancy, intended to bring the world into accordance with whether it is the result of rape or the lack or failure of a more private version of what is right and good contraceptives. The study made clear that the roots (Welty, 2005). of gender-based violence need to be dealt with, that women need better access to contraceptives, Both religion and culture are found to have including the morning-after pill, and that the legal a huge influence on SRHR: they affect the right to safe abortion needs to be realised. views, decisions and actions of policy makers, intervention implementers, service providers, The intersectionality of cultural and religious researchers and service users alike. Culture and values and their influence on SRHR requires religion shape views on sex (Jozkowski et al., integrated intervention strategies. Research to 2013), sexual orientation, gender identity and better understand the sexual and reproductive expression (Mkhize, Bennett, Reddy & Moletsane, needs of men and women in the study sites is 2010), gender and gender-based violence crucial. Whilst research does not lack in studies (Dartnall & Jewkes, 2013) and contraceptive use that link culture to SHR, these are not uncontested, (Mathenjwa & Maharaj, 2012; Moodley, Naidoo, owing to various research positions and negative Wand & Ramjee, 2015). and racial stereotypes that some of this knowledge can foster (Nduna & Mendes, 2010).

6 RESEARCH BRIEF 2 | JULY 2017 2. STUDY DESIGN Focus Group Discussions (FGDs) and Key This study was carried out by a team of researchers Informant Interviews (KIIs), following an open- from the Department of Psychology at the ended format, were used to collect data. FGDs are University of the Witwatersrand, Johannesburg. a good way of collecting data as they also present This Pietermaritzburg study is a component of a an opportunity for sharing of new information by wider programme of research and community- fellow participants, unlearning of old knowledge based development supported by AFSA to and re-learning. It is possible therefore that these advance SRHR in the Southern African region. discussions provided opportunities in themselves to create attitude shifts. This broader study was conducted in the Eastern Cape, KwaZulu-Natal and Mpumalanga in South The main findings are summarised under the Africa. The study, which received ethical clearance following themes: relationship dynamics, family from the University of the Witwatersrand, is nested planning and pregnancy, condom use, sexually within an AFSA Southern Africa (SADC) regional transmitted infections (STIs), access to health SRHR programme aimed at aligning sexual and services, communication between parents and reproductive health with culture and religion. children, sexual orientation and gender identity.

Data for this study were collected from black The report also presents a set of recommendations African women of varying ages, residing in based on these findings and on feedback received low to low-middle income townships outside by the research team from a member-checking Pietermaritzburg, namely Imbali, Caluza, meeting held with community stakeholders on the Mpophomeni and Maswazini. The entry point for 29 September 2015. recruitment was the Gay and Lesbian Network (GLN), an organisation that works on Lesbian Pseudonyms are used in reference to all research Gay Bisexual Transgender Intersex Queer participants. (LGBTIQ+) rights.

RESEARCH BRIEF 2 | JULY 2017 7 3. FINDINGS The suspicion of deceit held by women in Pietermaritzburg was echoed in the findings from Relationship dynamics Flagstaff (Case study 1 in this series). Young Coercion and violence men themselves disclosed possible ways of lying The findings on relationship dynamics reflect about their HIV-negative test results in order to normative constructions of relationships as deceive a partner and keep a relationship going heterosexual and violent, with different forms of (Nduna, 2016a). violence alluded to by the participants. Hegemonic notions of masculinities and femininities seemed Men here were also not trusted with their partner’s to influence relationship expectations and sexual HIV-positive test results. Women living with behaviours within and outside of relationships. To HIV reported that disclosure was risky for them locate sexual and reproductive health and rights because, upon learning the truth, a man could within the relationship context, studies of sexuality end the relationship, leaving the woman feeling need to focus beyond sex. In this study constant dumped for having HIV. As a result, as one reference was made to relationship character by participant said, men sometimes “… just carry the participants, in particular when describing on spreading [HIV] from one partner to another heterosexual relationships. Men and women’s one wherever you run to …” (Andile, FGD, young investment in romantic relationships was viewed as women, Mpophomeni). being different and unequal. In a dissatisfied tone of voice, a young woman in the Mpophomeni FGD This suggested that serial monogamy was a said “… the way things are going most men just love phenomenon for some women living with HIV as sex. [It’s] not that they love us as women”. This was a result of desertion by partners upon learning supported by data about pressure on women from about their status. Serial monogamy needs to be male partners to have sex even when the woman did discouraged as a public health risk in high HIV- not want sex. prevalence settings with low condom use. Related to the belief that some men were less Dishonesty about HIV-positive results was noted invested in their relationships was a lack of trust. for both men and women. For women, concealed Some women held the view that men could not HIV-positive status was motivated by lack of trust be trusted to be honest about their HIV-positive and a fear that their disinvested partners would test results and could deceive their partners terminate the relationship upon learning about their into believing that they were HIV-negative. The HIV-positive status. For men, an HIV-positive status Maswazini participants were agreed that was reportedly concealed, although it was unclear why some men would deceive their sexual partners “… a man will not agree to go with you and present fraudulent HIV-negative results. These [to the clinic]. They are stubborn; they findings suggest that there is a need to enhance go alone and when he comes back relationship communication skills about SRHR and he never shows his results, but he fight stigma against HIV to facilitate disclosure can change them (participants talked where it is necessary. Relationship communication simultaneously, agreeing).” (FGD, should emphasise the importance of honesty and young women, Maswazini) trust in stable unions. Men were presented as always wanting to do One of the limitations of this study was possible things their own way, an indication of gender- recruitment bias. The FGD facilitators were relationship power inequity. Women reported that responsible for recruiting potential study they could not get their partners to co-operate participants. This may have resulted in the attraction and listen to them, a finding that indicates how of people who were in abusive relationships and the participants felt about women’s status in knew the facilitators as volunteers within the health relationships. Couple counselling is available sector. Hence, there was a predominantly negative in some clinics in South Africa (Desgrées-du- view of relationships. Loû & Orne-Gliemann, 2008) and yet men were described as not interested in this.

8 RESEARCH BRIEF 2 | JULY 2017 “Due to romantic or emotional attachment “When you are younger there is not and social norms that support male that much pressure because it is your dominance in relationships, sexual choice; when you decide to have sex violence was not always readily identified you have sex, and the male asks nicely.” as violence by those affected.” This implied that although young women may There are various ways in which sexual violence act out of pressure from their boyfriends, it is manifests in intimate relationships. Due to romantic pressure that they can get away from as there is or emotional attachment and social norms that no commitment in these relationships. However, support male dominance in relationships, sexual for older women, relationship investments may violence was not always readily identified as tie them into unhealthy unions. For some, this violence by those affected. Experiences that could be a result of having a child with a man could be described as violent were presented as or matrimony. One woman said that “men really pressure to engage in sex. Participants appeared pressurise us because you have to dish up to believe that failure to respond immediately to a for him and if you refuse he will beat you up” partner’s sexual request could ‘justifiably’ result in (Thembeka, FGD, young woman). The term ‘dish physical violence. A woman’s freedom to agree or up’, a metaphor derived from the domestic chore disagree to have sex was constrained by her male of preparing and serving food, referred to giving partner’s reaction, including blackmail and the use of sex on demand. Others concurred. physical violence to get her to concede to his sexual demands. Intimidation was reported to be used by “It is true he will beat you up.” male partners who demanded sex because if a “… and you have to do it fast because woman “refuses, he goes somewhere else—he has you will get beaten.” (FGD, young a lady on the side” (FGD, young women, Maswazini). women, Maswazini)

This inherent relationship pressure was linked to In these data sexual and physical violence undesirable outcomes. One young woman said: were referred to constantly. Other research also reports forced-sex encounters for women “I think most people, especially girls, they (Mulumeoderhwa & Harris, 2013). Hence, it is fall pregnant because of the pressure important to educate people about Intimate that when your partner wants to sleep Partner Violence (IPV) early on in adolescence. with you, when you are not ready he SRHR interventions should promote mutual might say he will go somewhere else. In respect and offer women real options should they that way you try to keep him and end up wish to terminate a relationship. However, the pregnant unwillingly.” (Nu, FGD, young sense that men needed to be educated and that women, Imbali) their attitudes were a stumbling block to women’s realisation of SRHR prevailed in these findings. The reason given for men’s reported tendency to One young woman said: demand sex and seek it outside the relationship if refused was “… that’s how they [men] are” (FGD, “mostly … boys need to be taught young women, Maswazini). The essentialisation because all women are equal and they and naturalisation of men’s sexual demands know that but men don’t take that.” (Mbali, in relationships may result in women staying FGD, young women, Mpophomeni) in relationships, accepting that were inevitably disrespectful. Moreover, it takes away men’s Another said: individual agency by hiding their actions behind a culture that generalises their behaviour as the norm. “Family planning is only for women. Men are not included when in fact they are the Common sense might suggest that relationship ones impregnating girls in this community. dynamics improve with age, and yet young adult There are no actions taken in fighting that.” women from the Maswazini FGD thought contrary (Nu, FGD, young women, Imbali) to this. They suggested that:

RESEARCH BRIEF 2 | JULY 2017 9 Participants suggested that SRHR education them, involved in a sexual network with the girls was delivered through workshops and yet these at the tavern, through their husband’s behaviour. data indicated that face-to-face workshops were Wives were pitied here as innocent victims of HIV limited in these communities. Perhaps to avoid the risk through their mischievous husbands’ sexual logistical challenges and the higher costs of face- behaviour. to-face interventions, mass media in the form of print (newspapers, magazines, and pamphlets), At the same time, sex work, for instance, was radio, television, online media, such as internet viewed as a compelling choice for women from and social media, could be used more. poorer townships, where economic constraints presented limited livelihood opportunities. In this Alcohol abuse way socio-economic conditions were understood as There is significant evidence from South African shaping sexuality and sexual expressions, and thus studies of the problematic relationship between influenced socio-sexual practices. These findings binge drinking and unsafe sexual practices, such reflect the persistence of women’s gendered passive as unprotected and transactional sex. Taverns positions: women in taverns are observed to be in Pietermaritzburg and in other study sites were passive in relation to predatory men but at the same characterised by participants as places of unsafe time responsible for spreading disease. The passive sexual practices between strangers and drinking wife waiting at home is seen as a victim of sexually associates. Men and women were positioned transmitted infections because of her husband’s differently in relation to these practices: behaviour. Interventions are needed to activate women’s agency, especially their ability to protect “… if he is at the tavern and gets turned themselves from victimisation, blame and diseases. on, he grabs any girl and sleeps with her. What do girls say at taverns? She will Family planning, pregnancy and abortion sleep with any boy who brushes her thighs Counselling on contraceptives all night just so she gets a quart of beer, Family planning is an important aspect of and then she passes on the disease, and SRHR and services for both men and women. then the husband comes home with that Increasing access to and promoting consistent disease, whereas if men had workshops use of contraceptives require education and a that they attended, this kind of situation trusted family planning clinic that provides a full wouldn’t occur …” (Mbali, FGD, young range of services. Participants reported a lack of women, Mpophomeni) information, education and counselling about the contraceptives they accessed at their local clinics. In this scenario, men who drank in taverns Some participants complained that nurses did not were reported to behave in a predatory manner take the time to explain contraceptive measures. while women looked out for transactional sex Instead “they shove you with an injection” (Zandi, opportunities. The assumption here is that the FGD, young women, Mpophomeni). man is married and the girl a disease vector. Others reported more positive experiences. This discourse feeds into a historical myth that men cannot control their sexual desires, that if a “[They] … have to check if you are not man feels horny, he should have sex. ‘Grabbing’ pregnant so that they don’t inject whilst any girl suggests that the girl does not have you are already pregnant. You must agency. This constructs taverns as sites of sexual explain that it is your first time and you violence and indiscriminate sex. The girl at the have never done it before. Then they will tavern is further represented as a vector of HIV check all of that. They don’t just inject transmission. The ‘grabber’ is now the victim of you if it is your first time, never.” (Sane, this malicious behaviour. The man, who started FGD, young women, Maswazini) by feeling aroused and acted on this by grabbing any girl, is assumed to be HIV-negative until the girl “Well, they check your urine first and passes HIV on to him. Women whose husbands sometimes they tell you that you will go drink in taverns are presented as, unbeknown to on your periods—it might make you go on

10 RESEARCH BRIEF 2 | JULY 2017 your periods—or sometimes they ask you “I know someone who had an injection if you choose the two months’ injection and her body was fine before the injection. or the one that lasts three months, but Her body suddenly got fatter and she was now there is even one that lasts three wobbly and she turned into something years.” (Sisi, FGD, young women FGD, you don’t know—her body turned into Mpophomeni) jelly. (Nkuli) “That was caused by the partners she While experiences at family planning clinic services changed every day.” (Phill) were varied, participants agreed unanimously that there was little choice available to them. There was “No, she is married and lives with one also the sense that not much was known about the person.” (Nkuli) (FGD, young women, contraceptive implant. According to one young Imbali) woman, doctors themselves “are not sure if it’s a hundred per cent guaranteed” (Qando, FGD, Participants in the different sites seemed to young women, Mpophomeni). This uncertainty acknowledge the limited protection offered by has resulted in a loss of trust of the method. The hormonal contraceptives. At the Maswazini FGD, implant was consistently mentioned here, as in women understood that hormonal contraceptives other sites. It appeared to have overtaken the were limited to pregnancy prevention and did not three-month Nur-Isterate injection, which used protect against STIs like HIV. One young woman to be the more popular and commonly available from Mpophomeni said: prevention method among young people (Moodley et al., 2015). Not all participants knew about the “I think that … we all know that now there implant. Stereotypes, myths, negative attitudes are sicknesses, you know, that you might and misinformation around contraceptive use contract a sickness or fall pregnant. were shared in the discussions and these might Even if you went for an injection, you serve as a barrier to effective contraceptive use. must use a condom. Do not rely on that Some participants believed the implant caused injection because you don’t know what weight gain and flabbiness while others held the you might get in the end, because if you misconception that women’s bodies changed as don’t use a condom you get a virus or a result of their promiscuity, a view also expressed a child.” (Thembi, FGD, young women, among Flagstaff participants. Mpophomeni)

“We need knowledge about this Participants in the FGDs suggested that youth barcode they put now.” (Nu) SRHR centres were needed in their communities. This need was expressed in the Flagstaff site as “Barcode?” (Smah) well. SRHR services are sometimes rendered by “They put it here (using her arm to NGOs but these intervention programmes are explain the implant]. I heard about it at not usually sustainable since they are reliant on school. It lasts up to three years.” (Nu) volunteers with a stipend and do not have a wide reach (Nduna, 2016a). “I have never heard about an implant in Imbali [a Pietermaritzburg township], never.” (Phill) Pregnancy: ‘Phuthaliyenzeka, Nhloso, Delel’abazali’ “You need to make an appointment for Phuthaliyenzeka, Nhloso and Delel’ abazali’ it since it is a minor thing, just like when are some of the jocular children’s names that you are going for a circumcision.” (Nkuli) participants used during a member-checking “I can never do that, no.” (Thuli) meeting in Pietermaritzburg to refer to children born out-of-wedlock. If it was the first pregnancy it was “Would you rather take an injection regarded as a mistake because mistakes happen and after three months have a wobbly (iPhuthaliyenzeka). The person could be forgiven. body?” (Nkuli) However, in the second incident the pregnancy was “No, it doesn’t make your body wobbly.” considered to be deliberate and probably wished (Phill) for. Nhloso (aim or motive) means that the second

RESEARCH BRIEF 2 | JULY 2017 11 pregnancy was intentional. A third pregnancy you had a child at an early stage. Having a was regarded as a sign of disrespect. The name child at home is not a right thing. You must ‘Delel’abazali’ (disrespect the parents) suggests the have them when you are married because pregnant woman’s intention to provoke her parents. it is so wrong. Even when that person These names clearly suggest that a child born out-of- [man] pays ilobolo, the amount of cows wedlock was undesirable. has to be reduced, you see? Because now you had taken mom’s cow and given The right to choose when to have a child is a it to the boys [others laugh].” (Mbali, FGD, fundamental reproductive right, recognised and young women, Mpophomeni) protected in international law in declarations ratified by most countries. This right is easier to This ‘cow’ refers to the cow that would have realise for some than for others. Self-monitoring been paid to parents as part of ilobolo if the girl was evident in the data for young women. was a virgin.

“The rule is we should not fall pregnant at When a woman gets married in this community, all. We are supposed to sit at home and she moves out of her natal home to stay with her wait for marriage. But then modern times husband and his family. The couple eventually and olden days are different—we could move out of the family home to start their own not wait, we fell pregnant, had the first home. Raising a child in one’s birth home was child and had another one.” (Woman 5, reported to be a burden. Participants further FGD, young women, Maswazini) viewed it as irresponsible and a financial burden to have more than one child. In these data there was a sense that having a child was a necessary burden for heterosexual- “It is not right to have babies these days identifying women. It was expected that a woman because children end up poor. Even us, would have at least one child and the timing and their mothers, we are struggling; we do circumstances for the pregnancy were somehow not have jobs.” (Khethiwe) prescribed by social norms. “She who has babies should stay with “You know this thing of not having a the ones she has and not have more.” child by the age of thirty-something (unidentified woman) FGD, young … bones get stiff and you cannot give women, Maswazini) birth on your own … so we are rushing to avoid that (they all laugh)…” (Mbali, Participants’ thinking seemed to be confined by FGD, young women, Mpophomeni) the realities of their everyday lives in South African townships. When poverty and economic deprivation At the same time, women were judged for having become central to decision making, it limits women’s a child ‘too early’ or without being married and realisation of their reproductive rights. this was perceived as rushing for maturity against parental advice. In cultural and financial terms, Participants not only expressed a concern participants reasoned that having a child pre- about a woman’s current financial status but marriage reduced the value of ilobolo (bride predicted that poverty would continue into the wealth traditionally paid in cattle) for the woman next generation, hence the caution that: “these when it was time to get married. Childbirth out-of- children grow up hungry and they steal, they wedlock is common in South Africa (Ardington, break into people’s houses” and “it becomes Menendez & Mutevedzi, 2015). However, an your burden and the world is cruel now” (FGD, intersection of tradition and political economy young women, Maswazini). around this cultural practice may affect the realisation of women’s SRHR by undermining This worry suggests the commodification of their value and dignity. reproductive rights: only those who can purchase them can afford to enjoy them (see also Eshowe “You are not accepted rightly because report, Nduna, 2016b). This suggests a phenomenon

12 RESEARCH BRIEF 2 | JULY 2017 that reproductive rights may be infringed by the she has a child or children. ‘Having a child’ for the expansion of a neo-liberal global economy and participants meant having been pregnant which an emphasis on individuality and free will. Hence, equated to bearing a child. Previous abortions women in this study were worried about the impact and secondary infertility were also seen as a of poverty and deprivation on their offspring. They burden. For participants whose frame of reference were mindful that they would carry the burden as could be self-induced or backstreet abortion, the parents for the undesirable consequences of raising possibilities of having a future pregnancy were children in what they termed a ‘cruel’ world. The viewed as slim to none. As one young woman said: world was viewed as cruel on the basis of economic constraints and, additionally for girls, because of “I think that once you perform an their vulnerability to different sorts of human rights abortion, it is possible that you might violations, chiefly sexual violence. As one young never have kids again.” (Thembi, FGD, woman said: “… a stranger may just come and young women, Mpophomeni) rape your child and leave her with a disease” (FGD, young women, Maswazini). Discussing the causes of secondary infertility in women, a participant explained what she This worry is not misplaced as levels of sexual believed was a traditional view of abortion: violence against women are high in South Africa (Dartnall & Jewkes, 2013). Parents, and mothers “If you had an abortion … well, to others in particular, worry constantly about crime against it happens that they have a miscarriage girls and women because of their gender. This and then will never be able to have kids indicates high levels of social injustice resulting again. It starts deep from the traditions from the normalisation of Gender Based Violence because they say that it freezes the womb. (GBV) and the failure to provide support and The previous child needs traditional redress for victims and survivors of sexual ceremonies like Iladi (a ceremony where violence. In spite of the challenges associated with there is a lighting of candles and gifts having children, participants believed that it was for the person for whom the ceremony is important to “have at least one child” (FGD, young being performed) and you need to do all women, Maswazini). Having no children was of that and buy what you are told to buy viewed negatively due to a woman’s gendered for you to be able to have kids again.” identity, which was seen as primarily maternal. (Andile, FGD, young women, Maswazini) Having many children was also viewed negatively as demonstrating lack of insight and wisdom on the The ‘previous child’ here refers to the embryo or woman’s side for not learning from ‘her mistake’. foetus. This example further demonstrates the link between culture, traditional beliefs, rituals and Having a child was also seen as affecting a reproductive health outcomes. woman’s prospects of getting married. Ironically, the effects were constructed in both positive On a negative note, a child born pre-marriage with and negative ways. On a positive note, having another man was viewed as a burden and a liability. It a child was viewed as good because, as some was observed that wisdom, following cultural norms, participants argued, men were suspicious of a dictated that women should leave their children at woman with no child at all. their parents’ homes when they got married.

“Now most boys don’t want a girl with no There is anecdotal evidence that a section of the kids … like me, if I were to come up now South African population is opposed to the child and say I don’t have a child, he will look support grant (CSG), which is one of the social at me in another way and ask where do I benefits available for vulnerable children in South take these kids to?” (Qando, FGD, young Africa. In this study, as in others (Nduna & Bujela, women, Mpophomeni) unpublished work), the CSG was blamed for high rates of pregnancy among young people. This questioning insinuates that the woman has either aborted a pregnancy or is hiding the fact that “It is very hard on sex issues and then

RESEARCH BRIEF 2 | JULY 2017 13 they fall pregnant and say they want grant Others also reinforced this view. The fluidity money even. That money is nothing. That of sexual orientation and the gender identity money does not do anything. What can continuum seemed to confuse people. Though you do with R300?” (Women 7, FGD, older bisexuality was acknowledged, bisexual women, Caluza) people were not granted the freedom to live their lives. Community members demanded an Pregnancy for closeted lesbian and bisexual explanation and justification for gender non- women was also contested. Where bisexuality conforming behaviour. This was demonstrated was recognised, it seemed to be infused with a in the discussion below with multiple participants ‘progressive’ homophobia, under the guise of interrupting each other: concern for the children. One older woman asked: “No, no, no (‘No, Zama, it is what it is!’). “How was she sleeping with men and I am not against what you are saying. even having a child? We are not against Listen to me: that is why there are people her if she had been in the closet. If she had who are bisexual, transgender and so known of her feelings she should have on (‘We know their categories.’) That used a condom or used contraceptives person, I would say, they are selfish. or taken pills. But then now the problem They want to do it all. The reason they arises when she has children—that is had children is because they wanted to our problem: these children that she has know how it feels like. Then they decide brought to the world. What will they say they are not generous towards children. then? Will they say ‘dad-mom’?” (Woman In fact, it is not because they are selfish 7, FGD, older women, Caluza) but they are transgender…” (Zama, FGD, older women, Caluza) Children were used to evoke disapproval against same-sex couples. For participants, it was unclear Disapproving attitudes towards pregnancy out- how a bisexual person could consider having of-wedlock, the child social grant and pregnancy children and it was deemed an unacceptable and childbirth for bisexual women were not the situation for the child. The message was that the only problems facing women. The genitor’s sexual orientation of the mother would create response to the pregnancy also had negative confusion in the child. It would seem that this consequences. argument is consistent with that expressed by people who oppose homosexuality. The Paternal acknowledgement reproductive rights of bisexual women are The genitor’s reaction to a pregnancy varies—in questioned: they are expected to live their lives particular to early unplanned pregnancy. Where but to make sure that they do not get pregnant. the alleged father acknowledges responsibility Participants argued that bisexual women should and there is no misattribution, there is no problem, use contraceptives. If they get pregnant and have although this does not necessarily guarantee a child it becomes a ‘problem’. consistent child support. However, some young women experience their partners’ responses “It means that the person is selfish; they to the news about an unplanned pregnancy only think of themselves and no other as contesting and temporising. Qando in people or the community. What will the Mpophomeni painted a miserable scenario: children that you brought into this world think? Will they call you ‘father’ and “As women, at times we fall pregnant call their father ‘father’ as well? What and men love to have sex with you [but] happened to mother? She did not mean he will leave you and your tummy just to have children, no … why did she open like that … and you do not even want her legs? No they will not call her ‘mom’ that baby.” (Qando) but she will date women.” (Zama, FGD, older women, Caluza) “Men have rights. If he says the baby is not his, it is not his, and if you go and

14 RESEARCH BRIEF 2 | JULY 2017 have blood tests, [men] now have this considered to be from the paternal side of one’s habit of drinking traditional herbs and if family (Nduna, 2014). Children in some families are they drink that the results will reveal that thus stigmatised and any problems experienced the child is not his, even though it is his, with them in extended family formations could and that will hurt you.” (Qando, FGD, be attributed to the fact that the child “stays with young women, Mpophomeni) traditionally acknowledged children whereas he is not [acknowledged]” (FGD, older women, Caluza). The genitor’s failure to acknowledge paternity negatively impacted a woman’s ability to cope Choice of termination of pregnancy (cToP) financially. In the event that unprotected sex results in an unplanned pregnancy, a woman has, in theory, “A child ends up fatherless these days several options: to carry the pregnancy to term and and you as the woman end up struggling keep the baby; to give the baby up for adoption, on your own not knowing how you are if she is older than 18 years; or to terminate the even going to feed the baby and maybe pregnancy. Throughout the Pietermaritzburg you are not even working … For now, as sites, abortion was understood as an option you know, we do not have jobs and we that women had and various reasons for some have children. Their fathers just leave women to choose this option were spelt out. us.” (Woman 1, FGD, Maswazini) These reasons included relationship break-ups, fear of a parent’s reaction, financial constraints, Sometimes a man’s positive response to an contraceptive failure and parents forcing the unplanned pregnancy was viewed as him simply child to have an abortion. The following exchange tolerating the situation. The woman was then addresses the situations, in which a woman might expected to show appreciation for his tolerance choose an abortion: by preventing a future ‘mistake’ from happening, otherwise he would be justified in leaving her. But “Abortion happens if a person cannot a woman’s ability to provide for her child was still identify the child’s father. That is a negatively impacted. first reason. Secondly, it is because a person is scared of her parents. She “Fine, I had the first one and he stayed does not know what they will say about and he was patient … but comes the the trouble that she is in so she cannot second one, he hits the road and then I carry that child. Another person thinks am left with two babies, struggling, and the child will set them back. Life goes I have to chase after him looking for him on so they cannot sit and care for a child and not even find him.” (Woman 4, FGD, whilst they want to live their life, so they young women, Maswazini) cannot have a child.” (Andile)

The use of the word ‘patient’ was deployed “When a person has an abortion, I think instrumentally as if to suggest that the alleged it is because when she told her partner father had an option to leave. Paternal he may have run away because he does acknowledgement and connections with a not know how he will report at home that biological father are highly valued in South he has impregnated a girl … so because African communities (Nduna, 2014). Yet, there is the boy distanced himself from a girl she very little research on paternal acknowledgement ends up having an abortion.” (Zandi, in South Africa. This phenomenon needs to be FGD, young women, Mpophomeni) given adequate research attention as it affects men, women and children in dire ways. An unplanned pregnancy is not always unwanted. However, it may threaten a relationship. Some people who grew up without knowing their paternal identity are believed not to be protected “Sometimes you have an abortion with by the correct ancestors. As most South African this reason: maybe I have eight kids … groups are patrilineal, the ‘correct’ ancestors are how am I going to have a ninth child?

RESEARCH BRIEF 2 | JULY 2017 15 Maybe that child was not even planned, that include virginity testing, such as ukuhlolwa/ so the best way is to have an abortion Inkciyo, could lead to clandestine abortions because I cannot have nine children due to fear and shame of having had sex whilst without having a job. How will I care being a member of a virginity movement. Inkciyo for them? And sometimes you tell the (ukuhlowa) is a movement of maidens among father of the child, and he says he does some ethnic groups in South Africa, predominantly not want a child and that if you carry in the Zulu, Swati and to some extent the Pondo on with that child, then it is the end of communities. A concern was raised by participants your relationship, and then you end up here that parents’ experiences of shame, stigma aborting to make your love last?” (Mbali, and disappointment, and a harsh reaction to the FGD, young women, Mpophomeni) pregnancy may make them force their daughters to undergo a clandestine abortion. Contraceptive-use failure resulting in an unplanned pregnancy was another reason why “Sometimes our parents have a problem women choose abortion. about what will the neighbours think whereas the child was undergoing umhlolo “[You] had this injection that lasts for [and is now pregnant]. What will they say three years, because they say you now? So now the option is that a child cannot fall pregnant if you have it. So has an abortion so that the child stays in when you go to the clinic and find out position whereas the truth is she has been that you are pregnant but you are still off-position long ago, you see.” (Mbali, on this injection, so then you make a FGD, young women, Mpophomeni) decision to have an abortion because you did not plan that.” (FGD, young In this site, there was a degree of acceptance women, Mpophomeni) of abortion as an option for women. This was in stark contrast to the complete rejection For some of the young women, abortion was seen expressed in findings from Flagstaff, a Pondo as an option to help them reach their goals and to community only 258 kms from Pietermaritzburg, honour their parents’ aspirations, or because they and in Eshowe, a Zulu community 213 kms from found themselves stranded. Pietermaritzburg. Religion and culture were not emphasised as reasons against abortion. “Sometimes we have an abortion The only problem identified that was linked to because of the parents. You find that tradition was the non-performance of iladi, a ritual maybe you are still at school, you haven’t associated with childbirth. This could be because finished yet and then you fall pregnant. Pietermaritzburg has an urban influence, is less Maybe you are doing your matric or in conservative and more accepting of abortion as standard nine and you fall pregnant. a medical procedure. Maybe your parents had their hopes on you. Maybe they are not even working Women’s reproductive choices in the context and now you have to drop out of school of poverty are constrained. Unemployed and but you would still like to carry on with poorer women are increasingly finding it difficult school and they throw you out … so then to choose when and how many children to have. you resort to abortion.” (Thembi, FGD, This is dictated by money and so women’s right young women, Mpophomeni) to choose cannot be realised in this context. Women themselves constructed unplanned and These findings suggest that there is a need to or out-of-wedlock pregnancies in negative ways, conduct research to better understand the link similar to those in Shefer et al. (2013). between unacknowledged and denied paternity and teenage abortion. This link is implicated in a Safer sex/condom use qualitative study from the Eastern Cape on young Condoms, predominately male condoms, women in distress (Nduna & Jewkes, 2012). continue to be promoted as an effective HIV- These data also suggest that certain practices prevention, public-health intervention method

16 RESEARCH BRIEF 2 | JULY 2017 for safer sex. Using a condom correctly and Where such binary views are shared by health consistently remains one of the most reliable service providers, it means that heterosexual and ways to prevent pregnancy and STIs, including LGBTI people may not be offered the services HIV, for men and women. Availability of condoms or products they require equally. Restricted or is important if this method of prevention is to be selective access to condoms, which does not encouraged. Further to availability, access to respond to actual needs, undermines prevention condoms for everyone who needs them is critical. efforts across society. Utilisation is key to making sure that STI/HIV and pregnancy prevention is achieved. This section “The reason I say there is lack of explores these three sub-themes that emerged knowledge is … well, I am going to in the discussion about condoms: availability, make an example. You know when I go access and utilisation of condoms. for blood tests, they ask me where is my boyfriend. And they ask if we use a Availability of condoms condom, even though they know of my Availability of condoms at clinics and at taverns sexuality. Also [there is a need for] the was confirmed across the nine research sites in distribution of lubricants to the LGBTIs the three provinces. However, there were different and to heterosexuals as well, and in perceptions of availability of condoms within and the clinics there are no condoms for across communities. This suggests that there homosexual people.” (Phill, FGD, young is not consistent availability and so participants women, Imbali) could have different experiences with obtaining condoms at different times. In these data, as with Access to condoms the other sites, availability of freely distributed Clinics seemed to be the main sites of reported government ‘Choice’-branded condoms was condom distribution and participants felt that commended by participants. However, there were this was not enough. Sometimes condoms challenges with availability of other protective were reported to be distributed in taverns, but products, as reflected in this exchange: participants argued that more could be done to make them accessible privately where they were “We were at a workshop where they needed. The following challenges with access talked about condoms for gay people, were brought up: so I do not know if they have them in our clinic. There is one for the tongue and “I wouldn’t say that condoms are not one for hands and so forth. Where do there. The issue is that most people those come from?” (Woman 9) are scared of taking condoms in the presence of other people, especially in “No, we have not heard about them.” taverns or in public spaces.” (Ayanda) (Women 7, 3) “Some people fear taking condoms in “We only know the femidom, for women. front of other people because of the Oh, that is better. There are now comments that people make when they condoms for fingers as well.” (Woman see you taking a condom; they just 7) (FGD, older women, Caluza) assume you are going to have sex on that particular day, so next time when This discussion referred to lubricants and dental you know for sure that you are going to dams. The reference to ‘condoms for gay people’ have sex you fear taking a condom in suggested a belief that gay people engaged in the presence of other people.” (Thuli) sexual activities that heterosexual people did not. Whilst lubricants and dental dams are mainly used “Well, I think that … how can I put this? … by gay and lesbian couples, people who identify as sometimes you look at it this way: having straight also engage in anal and oral sex so these sex is a private thing so now taking a products would be useful for all groups. This idea condom in public just shows people of exclusivity contributes to the stereotyping and what you are going to do (laughter).” stigmatisation of gay and gender-variant people. (Nu) (FGD, young women, Imbali)

RESEARCH BRIEF 2 | JULY 2017 17 Sex is a subject that excites and yet embarrasses Utilisation of condoms people. Inappropriate and untimed comments Consistent and correct condom use is important for about sex could be experienced as embarrassing optimum protection against STIs and pregnancy or harassing for some, and thus could dissuade for sexually active persons. Where condom some people from acting responsibility in relation distribution enables access, the next important to their health, for example, in picking up condoms step is that condoms should be used. Even where in front of others. Participants were concerned condoms were available in different places, apart about ignorance regarding condom use and from clinics, the likelihood of them being used was suggested that condom distribution should be questionable. Participants spoke of circumstances accompanied by education for the users. One that did not support condom use. young woman said that people should be taught about family planning in taverns “because many “Most people drink and when they are girls that fall pregnant are from taverns”, (Zandi, drunk the chances of them contracting FGD, young women, Mpophomeni). infectious diseases are high because when you are drunk you do not think straight, you Other participants suggested that condoms see. Short-term pleasure does not pay out, should be issued in churches and schools. because they say skin-to-skin sex is more enjoyable (laughs) than sex with a condom “A lot happens during goodwill church (everyone looks at her and she responds to conferences. I saw it this year people the nonverbal communication). Seriously, having sex at night. And in schools as well, that’s what they say. And another thing, they should be put in the toilets because people get drunk in this area so when we have sex at school too (laughter).” everyone is drunk people grab whoever (Nkuli, FGD, young women, Imbali) they want to grab to do their business.” (Nu, FGD, young women, Imbali) There were conflicting ideas about the distribution of condoms at schools. All participants across the The focus on places where reckless sexual different FGDs agreed that it was logical to have behaviour occurs was not misplaced. At the condoms at a place where most young people same time it should be borne in mind that unsafe have access. The aim of extending condoms sex also happens in encounters between regular distribution to schools is not to encourage or and intimate partners, which could be as risky as enable children to have sex but to make condoms well where there is infidelity, unknown HIV status accessible to young people who are becoming and no condom use. The importance of safer sexually active and might not have access to practices, including use of condoms, in what a youth-friendly clinic. There was contestation seems to be a stable relationship should also be around the young age of school-goers and the communicated continuously and consistently in expectation that learners should not be having sex HIV-prevention messages. yet. However, there was recognition from some of the older participants who, as parents, supported Despite admission that access to (male) condoms the distribution of condoms distribution at schools. was not a problem, consistent use of condoms remained a challenge for some women. “This issue of distribution of condoms at schools … we as parents think the “As women we face challenges that government is corrupting our children sometimes you find that a man doesn’t and encouraging them to engage want to use a condom because men into sexual activities at school. The want flesh against flesh and now you will government is saying they do it anyway end up, since you love your partner, you no matter what, so they are trying to end up offering him flesh against flesh, solve problems and they are saying whereas if there were female condoms since you are ready to do it then here distributed accordingly, you will take is a condom—use it.” (Woman 7, FGD, them and if he wants flesh against flesh older women, Caluza) you give it to him and feel comfortable in

18 RESEARCH BRIEF 2 | JULY 2017 that way.” (Zandile, FGD, young women, come back again … They weren’t Choice. Mpophomeni) It was the ones with flavours.” (Mzet) “Men do not want to use condoms and “… and fancy, so that you know when we need to just agree with them on that.” your partner is visiting, you take the (Woman 4) fancy ones. You know with the red package (everyone laughs) … and even “Men say, ‘If you want to use a condom, their female condoms. They were the then we would rather not do it.’” (Woman ones with the sponge, not the ones with 7 FGD, young women, Maswazini) a rubber band.” (Phill) “You see, even when you are married “They have a sponge?” (Thuli) he will just say ‘… since I married you I won’t be able to have sex with you with “(Uses hands to demonstrate) It is like a condom on’. Meanwhile he knows that this (horizontal position). It has rubbers he is cheating on the side, so you might on both ends, so instead of rubber enter a marriage with both of you having bands, the ones that were supplied had negative results but as soon as you are sponges.” (Phill) married he goes out and cheats and “Oh, so the sponge goes inside?” (Thuli) comes back to pass it on to you.”(Mbali, FGD, young women, Mpophomeni) “Yes, and it sucks dirt in, well, not dirt but the offspring of the person you Coercion through intimidation and manipulation would have slept with.” (Phill) was commonly reported by women as preceding “It is hot, hey?” (Sma) (FGD, young encounters of unprotected sex with their partners. women, Imbali) Love, relationship commitment, conjugal ties and fear of losing a relationship all contributed to ‘Sucks dirt’ here referred to absorbing the semen. women giving in to sex without a condom. However, It is a common understanding in some of these participants recognised the importance of women communities that semen (and vaginal fluids being able to exercise agency because they have including menstruation) is dirty. The ‘dirt’ referred to deal with the consequences, and be blamed for to potential infections that could be contained them. So they cautioned against non-use. by such fluids. At this point in the discussion, a facilitator distributed female condoms so “What we need to be careful about, if you everyone in the group could see what was being were to be sick now with a discharge and referred to. have to go to a clinic, at the clinic these days, they ask you where do you come This discussion indicated a strong interest among from with a sexual infection these days? participants in incorporating barrier methods of Two: if you have sex without a condom, HIV and pregnancy prevention into what should you are expecting to have a virus and a be pleasurable sexual activities. This suggests baby …” (Qando, FGD, young women, a motivation to overcome resistance among Mpophomeni) partners to condom use and a desire to exercise agency. These aspects are very important in In terms of condoms, people are looking for addressing the attitudinal and practical obstacles variety to encourage use. In the Pietermaritzburg to condom use, as freely distributed government site, as in Flagstaff, research participants found condoms are rejected across board by young the routinely distributed, standard Choice people (Nduna & Mendes, 2010). Colour and condoms boring for a variety of reasons. They flavour were suggested as factors in choice and expressed preferences for flavoured, textured acceptance of condoms. Since April 2015, the and attractively packaged condoms that an NGO South African Department of Health (DoH) has once provided in this locality. started distributing a variety of condoms in pilot sites, mainly institutions of higher learning, aimed “Their (unnamed) condoms were different at overcoming the challenge of young people’s and people liked them. Maybe if they could lack of interest in Choice condoms. These

RESEARCH BRIEF 2 | JULY 2017 19 flavoured and coloured condoms are fondly A ‘jam’ is local slang used to describe small known as ‘Max’, for maximum protection. gatherings similar to parties where people gather and bring alcoholic drinks to share. Education about condom use The participant implied that in these drinking There was a sense that the female condom was spaces opportunities presented for casual sex, easier to use and an answer to men’s refusal sometimes forced, and, at times, transactional to use the male condom because, with the and consensual. femidom, a woman has control. Research reports that even though the women insert the femidom STIs and HIV/AIDS it does require communication about use with the There were knowledge gaps concerning STIs partner (Maharaj & Mahlalela, 2015; Mathenjwa including HIV. Myths around the ‘shower effect’ & Maharaj, 2012). It is not entirely secret, but it (the false idea that showering after sex could has evolved and improved to address some of reduce HIV risk) (Nduna & Mendes, 2010) were the complaints about its discomfort. The following voiced and partially correct knowledge was comments reflect both that the improved femidom infused with misinformation. was more user-friendly but also that there are problems of availability. “Firstly, you do not contract sicknesses easily if you are circumcised, you see. “Sometimes you would not find condoms You do not easily contract an STI because at the clinic whereas they should have if you have just finished getting naughty all kinds of condoms. Mostly there are as a woman or a man you have to wash male condoms; female condoms are yourself afterwards. Both of you should rare and sometimes you find that they bath. Even if you do it the whole night, you are there. As women we like to use must have bathing water for when you are condoms, and as women we look at it done. They must have a Dettol and soap as … in our clinics we are not important, so that you do not contract sicknesses men are more important than women easily.” (Andile, FGD, Mpophomeni) because you only find that the condom boxes are filled with male condoms, you Participants attempted to convince the group that will not find female condoms.” (Zandile, some people might look like they had AIDS and FGD, young women, Mpophomeni) yet their HIV test might prove otherwise. They might be sero-discordant, whilst others might “You can wear it and go. It does not have a have undetectable viral loads. problem. My sister, it can stay for six hours in your private parts—it gives no problem. “You see, someone may be positive and And I think it is very good for people who reflects positive on you, but his blood like to jam because when they taught may reflect negative and he comes to us about it … and I thought it was good you and shows his results and says I do because at the jams, even if you are not not have anything.” (Woman3) raped … sometimes there is no asking “Yes, men are strong. Some even die each other. If you are with your boyfriend without it reflecting and some just carry but you see someone else and see that it and spread it.” (Woman7) they have money, he will just wink at you and then you go outside and do your “Can I just say that not only in male business and come back. So, in that way species where the reflection is low, even it is safe because when you are done you in female species sometimes, it hides. take that condom out and fold it and put on It may not reflect but it’s there (They another one (others nod at this description mumble an agreement).” (Woman4) and exclaim softly in agreement). So, I “Listen, even if he does have it, he thought it was good for us who jam …” comes back and says he is negative (Woman 7, FGD, older women, Caluza) and he goes somewhere else, it does not reflect immediately; it reflects after

20 RESEARCH BRIEF 2 | JULY 2017 a certain period of time. It depends on a Strengthening knowledge about various aspects person’s blood type … and sometimes of SRHR remains a challenge. This ranges from you may even die without reflecting and understanding of consent, the right to information sometimes it depends on your CD4. A and quality services, to basic information about woman’s CD4 is facing upwards and it the female body and sexual pleasure. This lack receives immediately, and a man’s CD4 of education and the resultant ignorance was is facing downwards.” (Woman1) (FGD, reflected in the discussion at Maswazini about young women, Maswazini Choice condoms versus commercial condoms. Young women here seemed to agree that freely These statements demonstrate a misunderstanding distributed male condoms caused vaginal of HIV infection dynamics, including (mis)reading dryness, itching and a rash. of viral load information, sero-discordance and the window period in relationships. This discussion “When you have this itch it is like a small also proved that some people still judged other’s rash, but yet you cannot see it … you HIV status by looking at them, despite education to only feel the pain.” (Khethiwe) dispel this ‘slender disease’ myth. “Maybe it is this oil they put in them.” (Thembeka) One of the simple ways to explain increased biological risk for HIV infection for women is “Yes, it’s exactly like that—it feels like a to explain that the vagina receives and retains rash but it’s very painful.” (Gugu) (FGD semen. It would seem from this example that this young women, Maswazini) lay explanation was completely misunderstood. A similar situation was evident with the understanding Notwithstanding a possibility that some people of the immune system. may experience allergic reaction to latex, by and large these are signs of sexually transmitted and “There is a CD8 and a CD4; if you have a other infections. Some participants incorrectly CD8 it means your immune system is in believed that lubrication was used on condoms one direction, your immune system fights in order to prevent STIs. There seemed to be a illnesses. When you have a CD4 it means problem experienced with condoms when the your immune system is not in the same lubrication was considered to be excessive as the direction so when you get illnesses your condom would get slippery and come off during immune system cannot fight because use. On the other side, too little lubrication was the illness finds a part where it hides and reported to result in dry and painful sex. you end up HIV positive and have AIDS, whereas if you have a CD8, your immune Either way this could inhibit condom use. The system is in one direction and it can fight participants here, and elsewhere, did not seem illnesses because they are in one place to consider or know that other factors could affect as soon as the virus comes in, they fight sexual pleasure, with or without Choice condoms. because they are in one place and not A woman’s vaginal lubrication differs across her scattered. You may even die negative.” lifespan and at different times in the menstrual (Woman 2, FGD, older women, Caluza) cycle. Readiness for sex, romantic mood, stressors, treatment side-effects, contraceptive side-effects, There seems to be an urgent need to address etc. could potentially affect vaginal lubrication the Information Education and Communication and sexual pleasure (Jozkowski et al., 2013). (IEC) gaps about HIV. Some research reports Sometimes, vaginal problems such as itching that people are AIDS-fatigued (Shefer, Strebel, and rash are an indication of sexually transmitted & Jacobs, 2012) and yet this data reflects the infections (Mlisana, Naicker, Werner, Roberts, need for consistent and continued education to Loggerenberg, Baxter, Passmore, Grobler, Sturm, disseminate correct information. More important Williamson, Ronacher, Walzl & Karim, 2012). here is the need to develop local language Correct recognition and labelling of conditions is materials to communicate scientific information important in health-seeking (Jozkosk et al., 2012) correctly for better understanding. and this comes with knowing about the signs and

RESEARCH BRIEF 2 | JULY 2017 21 symptoms of STIs. However, participants attributed door during the day (no weekend and no public their negative sexual experiences to the Choice holiday work), or at clinics, also during the workday. condom. Partly, this could be a reflection of lack A sense that men were a bigger part of the of education about STI signs and symptoms and it problems experienced by women in relationships could mean that these STIs are left untreated. prevailed, with calls to teach men about SRHR made. As one participant put it: Access to health services Participants reported positive and negative “[Men] are stone-hearted; they do not experiences with healthcare services, particularly want to understand and they do not in primary healthcare clinics. On a positive note, believe that this sickness exists. And the participants who were living with HIV and were on way they do things, they do not like the antiretroviral (ARV) treatment reported that there clinic. They never think of going to the were good changes in the way that ARVs were clinic.” (Sbongile) delivered. This was an example of progressive and improved services that made the service accessible “I think that there should be more and easier for them, thus improving adherence. workshops for men and there must be more people who will be trained “There is a medi-post when you go to and educate men. (There is a short the clinic. You do not have to stand in argument.) Others are educated but line like before where you stood in long they don’t like to visit the clinic.” (Mbali) lines with many people and it would take (FGD, young women, Mpophomeni) time. I think the government has reduced our problems for us that have to go and If the African community generally is conservative, collect our medication.” (Woman7) men were viewed as more so. Women viewed themselves as liberal and thus more responsive “Now it has changed; if you book an to SRHR education than their male counterparts. appointment for a certain day, when Instead of listening to the ‘SRHR gospel’, men you get there you find the doctor [is were reported to pose a challenge for educators. present].’” (Woman 3) (FGD, older women, Caluza) “When we conduct a door-to-door, sometimes you come across men and Improved antiretroviral treatment (ART) clinic those men will not take you seriously service was also reported in Flagstaff at the and they just think they have scooped a member-checking meeting a year after baseline girlfriend.” (Zandile) data were collected. “I think the way she explains it is that Participants from sites outside of Pietermaritzburg they do not take your work seriously. spoke about distance as a geographical barrier to While you explain about your work/task, access the clinics and availability of all services. they step over the line and tell you that For those in closer proximity to town, such as Imbali they love you.” (Mbali) (FGD, young and Mpophomeni, access was not a problem. women, Mpophomeni) Further out of towns and cities access to sexuality education was reduced. Living on the outskirts of This insinuation of sexual harassment can potentially the town was also reported here, and elsewhere, create a gender-hostile environment for female to limit access to services as well as education and community workers. In addition to the distance to information about SRHR (Nduna & Mendes, 2010). the clinics, which is a structural barrier, and the Mobile clinics were available, albeit not accessible resistance of men, some health workers’ attitudes to all in remote places. Some progress to increase were also said to remain a barrier to improved services had been made, yet it was not enough. sexual and reproductive health outcomes. The timing of health education provision was also questioned as it excluded working members of the “What I see is that teenage pregnancy community because it was usually either door-to- is high, reason being they are scared

22 RESEARCH BRIEF 2 | JULY 2017 to go to clinics because nurses have Africa and results from unmarried, separated, an attitude … (there is a murmur of widowed and divorced couples (Roman, 2011). agreement). A nurse does not have a Single parenting resulting from divorce is higher right to tell that you should not take an amongst the African section of the population. injection because you are still young. It Talking to children about SRHR seemed to be might happen that you may fall pregnant experienced with difficulty by parents. The next and maybe you even have many section explores this. boyfriends and if you fall pregnant you would not be able to tell who the father Communication about SRHR is. So her job is to advise you then give Here, as in other sites, respondents saw a need you the medication that you need and for open and honest communication between not give you an attitude.” (Mbali) children and their parents about sexuality. Phill suggested that “there is a need for you to sit down “Another thing, on the point of teenage with your child and talk to her” (FGD, young women, pregnancy, it happened when I was at Imbali). Data analysis uncovered particular ways the clinic recently, when a girl came in of communication that parents employed, one for an injection … there was a comment that was dominated by reprimanding but came that ‘Now here comes the matric ball from a place of love and fear amongst parents. gang’. So when they say that, how is that This was mainly expressed as fear that a teenage child supposed to feel? When they say daughter would have an unplanned pregnancy, a the ‘matric ball gang’, [it means] now it position expressed vehemently in Eshowe (Nduna, is the time for the school kids to go to 2016b). It is this fear that leads to parents giving a matric ball. When girls come for an their children the ‘Don’t’s rather than the ‘Do’s. One injection they are saying that they are woman expressed it this way: “Hey, girly, never doing it for a matric ball.” (Zandi) get a boyfriend do you hear me?” (Woman 3, FGD, “Well, if you go to a clinic and find older women, Caluza). Parents found themselves someone with no care, even if the communicating in these ways because of their medication is available, she would not ‘heartache’. Similar to findings from Flagstaff, offer you because she has no care. She this admonishing approach was recognised as has her business that she is thinking ineffective by the participants, including those who about, whereas if they hire people with were parents (see Nduna & Vilanculos, accepted for care they would not give up work to publication). There were suggestions in all the FGDs focus on their things.” (Mbali) (FGD, about the importance of effective communication young women, Mpophomeni) based on clear information and free of shouting, and yet there was evidently hesitation to do this. It would seem that the persistent problem with nurses’ attitudes prevails nationwide as it was “I hear what the lady is saying but it is reported in all seven sites and it is discussed in hard. It is hard talking to a child telling recent publications (Meehan et al., 2015). This her how to, what can I say … well, they dissatisfaction was coupled with lack of trust of are girls right? You cannot allow yourself, duty bearers to whom challenges with the service because you love your child, you cannot providers were reported. Community members tell her how to wear a condom. So I do did not always trust that their concerns were not know how it could be possible that escalated to the higher offices to be addressed. we talk about this issue because you wish to talk to your child but still think Parenting and SRHR they are too young whereas, on the other Across all the FGDs most of the participants part, they are grown so us parents we had children. Some had children when they are in trouble.” (Woman 3, FGD, older were younger and reflected on this during the women, Caluza) interviews. In the main, parenting was seen as a difficult role in contemporary society. The main obstacle seemed to be a perception Single maternal parenting is common in South of what was culturally appropriate to do from a

RESEARCH BRIEF 2 | JULY 2017 23 perspective of an African Zulu community. The someone else (Others utter ‘mmm…’ in next section explores this dilemma. agreement). It is hard teaching your child. We are Zulus from olden days, like she Black racial identity culture and parent-child has said (pointing at a fellow participant). communication (PCC) It is not easy to talk to your child about The need for parent-child communication and condoms. How do you even start? Rather education around sexuality was not contested have someone else talk to your children at any point. However, participants struggle to for you or their peers (Woman 3, FGD, conceive of a way of doing it. Some suggested older women, Caluza) that children should be allowed to bring their romantic partners home and introduce them to The extract below suggests that the discomfort the parents. was shared by both parents and children: “X knows my daughter … she is old “It would be easier for parents to talk to but she can never talk to me about her their children because if you sit Mpilo boyfriend. But I know she has one, but and her partner down and tell them of she cannot tell me: ‘Mom, me and my the consequences they will face if they boyfriend went and did this’. No, it is ever start to do anything, they might hard even if I hint and tell her to go to listen better and I am sure they would the clinic to get tested. But I would not not do things they are not supposed to tell her straight. I will hint and she also do, it will be alright.” (Phill) would not tell me straight that she uses a condom, she will just say: ‘Ey mom’, and “Even if he starts troubling you it will she gets up and leaves me and I would be easier to tell your mother that your not chase after her either. We Zulus, our boyfriend is doing things you do not children fear us even if you have not said agree to.” (Mpilo) anything because it is in our blood as Zulus … respect comes naturally. You Participants reverted to their identity as (black) can never tell us of such things … tell me Zulu parents in a way that made it sound natural about sex, never! Even in the olden day and essential that children are dealt with firmly. we had amaqhikiza (people who guide women who have chosen boyfriends) “The problem with black parents is that that will tell you that: ‘Now, young lady, I do not know whether they are shy or since you have chosen this you will have what in talking about these things with to do thigh sex (called soma in isiZulu) their children, even about love. I do not and when you soma you sleep with your want to lie, a person will tell you that they thighs closed, but even in thigh sex if a love you only when they are shouting mistake happens and it goes inside you (imitates a shouting parent and everyone fall pregnant’.” (Woman 2, FGD, older laughs in agreement). You see she tells women, Caluza) you that she loves you while shouting.” (Nu, FGD, young women, Imbali) Parents had fears and anxiety about seeming to be leading their children to have sex. They The participant added that “our culture does not even considered asking other women to talk to allow … this thing of sitting down and having a the young woman and take her to the clinic. This talk with an elder”. Participants examined the would ensure that the young woman maintains challenge of African values in relation to age and respect for the parent. Some participants agreed etiquette, and the respect that should be paid to that being strict with the child did not help. women. One suggestion made about overcoming the communication barriers was to share the “Sometimes being too strict does not parenting role with other women. help … I am not saying that you should be too friendly towards the child, but “It is better if you tell your child to go to you should set boundaries. A child

24 RESEARCH BRIEF 2 | JULY 2017 will stay in a hot situation because she involved with?’ even when watching [the is scared of her parent. I stayed in a TV soap opera] Generations. She refers hot situation for fourteen years in my to love the same way. She says: ‘Oh, marriage because I was scared of my Karabo is now involved with Tau’. She parent. I could not talk to her and tell her never says they are in love, so where I was burning [could not take it].” (FGD, would she start with me?” (Mpilo, FGD, older women, Caluza) young women, Imbali)

At the member-checking meeting in Lack of information about SRHR was reported to Pietermaritzburg, parents also discussed the be behind some of the attitudes that parents held strategy of finding another woman to talk to one’s towards SRHR rights and services. Ignorance daughter as a way to deal with the need for parent- breeds ignorance and the view was expressed child communication on SRHR matters. A similar that black people “are not knowledgeable” suggestion was put forward at the Flagstaff and (Woman 3, FGD, Caluza). This claim to inferior Pietermaritzburg member-checking meetings. knowledge amongst black people has stood Some of the participants acknowledged that the test of time (Nduna & Mendes, 2010). These times have changed. One said: “There is no fear findings also communicated a sense that family now; children must be told.” (Phill, FGD, young discord in black communities was rife. Black women, Imbali). families suffer the detached and uninvolved men phenomenon resulting in a high prevalence of If not opting to use amaqhikiza, some participants single maternal-parented families (Makiwane, suggested that a language that toned down the Makoae, Botsis, & Vawda, 2012). One participant taboo could be used. compared black and white families thus:

“Like my mother, she does not mention “The problem is that white people try to the word love. She says: ‘Who are you commit themselves. Like if there is both

RESEARCH BRIEF 2 | JULY 2017 25 parents, they involve themselves in their “What do you mean when you say that black children’s lives, but with us black people, men are sperm donors? Because even the men are just sperm donors so it’s not white people sometimes they impregnate easy just bringing a partner home. I do someone and then leave. Are you saying not know how I can put this, but a father white people are better?” (Nkuli) is a male person, so he will understand “Most, most, they have a balance; most that the boy has come with intentions that white children are raised right.” (Nu) are … eeish … I do not know how to put this … but our families as black people “I do not know why we black people are not the same as white people’s. The cannot do the same.” (Mpilo) thing is we were raised by our mothers “Black people do not like to be at the so we do not have any relationship with top of the game.” (Nkuli) (FGD, young a father, unlike a white child. Like I am women, Imbali) referring to the unity of your family … it is not like white people’s because even This was a conversation among young women. when white people are divorced, when Sometimes the basis for the disagreement and they fight for a child’s custody, they plan arguments to deconstruct this image of black how the visitations of a father will go, people was hypothetical. unlike with us black people. It is a woman who stands for everything.” (Nu, FGD, “Us black people are not the same. young women, Imbali) There are black people who do as white people do, but there are some who The challenge here is that biological mothers do do not do that, like me, I can bring my not always raise children; the grandmothers, who chikita … [referring to girlfriend] home were reported to parent the ‘old way’—meaning and introduce her as my partner.” (Nkuli) that they were reportedly conservative—commonly raised children. The collective experience of single “Have you ever introduced your partner mothers evoked views against early and out-of- to your family? (They all laugh.) (Mpilo) wedlock sex if they themselves fell pregnant under “Oh please, I am making an example.” these conditions. Participants seemed motivated (Nkuli) to change the situation for their own children so “Yes, but have you introduced her?” (Mpilo) that they do not raise children with absent fathers. A similar view explains findings from a recent “They know her.”(Nkuli) multi-country teen pregnancy study (Odimegwu “And they accepted her?”(Mpilo) & Mkwananzi, 2016). Participants’ strategy, as parents, to change this was to discourage youth “Yes, but she is scared of them, but she sexual relationships. has been home, but she is scared of them.” (Nkuli) It is not always the case that mothers in two- “Now you are telling us a tale.” (They parent families deal better in parenting. Research all laugh.) (Nu) (FGD, young women, from South Africa records positive attributes and Imbali) evaluations of single mothers (Roman, 2011). Single mothers need support in raising children, Participants here, as elsewhere, discussed the both material and social support. Of course, right time to start giving sexuality education to these self-fulfilling prophecies and ideas about children. black parents as unable to communicate with their children due to age-respect-culture were “It should start when they are still young. contested also. They should not wait for them to be eighteen years old because you cannot “Don’t say ‘black people’; don’t include start that conversation at eighteen.” (Phill) all of them because there are some who “They should start at ten when they are are knowledgeable.” (Nkuli) still young.” (Nkuli)

26 RESEARCH BRIEF 2 | JULY 2017 “Not just with girls, boys as well.” starts with parents.” (Mbali) (FGD, young (Ayanda) women, Mpophomeni) “Yes, because they start dating in Preference for styles of communication was grade five.”(Nkuli) (FGD, young women, for authoritative rather than authoritarian Imbali) communication as the latter was viewed as ineffective. The women at the Mpophomeni FGD, who were young parents themselves, disagreed on the “And you should not shout at the child influence that they should have on their children. but rather talk nicely and she will do Some participants had their children when they what you want her to do, and she will be were teenagers and held a view that parent-child open with you and even tell you about communication was good to prevent experiences other things.” (Sisi, FGD, young women, similar to theirs. Mpophomeni) “Sometimes a parent and a child talk and “Then that means there should also be the parent would advise the child and tell a workshop that will focus on parents to her wrong and right things, so actually if create that relationship with their children.” you are a child, whether girl or boy, you (Nu, FGD, young women, Imbali) should talk to your parent … be open “That is why there should be workshops with your parent and she should also tell for women or forums so that they can you a wrong and right thing …” (Sisi) talk about these things, you see?” (Phill, “No, for me, I grew up living with my FGD, young women, Imbali) grandmother and she would never say Whilst there are challenges with parent- anything. Now I am talking on the note child communication in South Africa, to that these kids that we have. We must frame this as a race issue inadvertently be able to talk to them so that they creates problems. There are other would not fall pregnant at an early stage coinciding social and political factors like us.” (Sisi) that distinguish black and white people “Like me, you see, I have got two children. in South Africa, chief amongst these is Maybe if my mother was able to talk to class. Hence, the difference maybe at me about things, maybe all of this would a latent level and manifest as a cultural not have occurred, maybe I would not problem for a group of people racially have had kids, but my mother hid things categorised as black. from me… I asked her why is it that my friends go on their periods and I do not? Parents’ role in SRHR realisation I had my first period when I was 22 years Parents have a bigger role to play in terms of … and my mother was scared to talk to assisting their children to realise their SRHR. This me about the periods issue. She never role was understood as to protect the child and told me that to go on your periods you this was conveyed as potentially possible through will undergo such stages like growing instilling discipline. One young woman suggested breasts, but I had to look at my friends that parents needed workshops on the rights of and I wondered why do they have their children. “The way that they act shows that they periods? Why do they have boyfriends? are not educated. We are in a mess because Is there something wrong with me? Do of our parents.” (Mbali, FGD, young women, I need to go on my periods to have a Mpophomeni). Some said that some parents had partner? Even when I had a partner I already started to do this. did not know that I had to prevent and condomise, no. All I knew was that if I go “Other parents take their daughters to a man he has to touch me and then to the clinic for family planning and I have to open my vagina and we have sometimes you find that there is a sex, you see? Mistakes occur like that, it circumcision programme and parents

RESEARCH BRIEF 2 | JULY 2017 27 come in to sign agreement forms for do that to protect their child from such their sons to undergo the process. You situations. At least she should not have a see that sort of thing.” (Sisi, FGD, young baby. But another person may look at it women, Mpophomeni) in a way that maybe we are encouraging them.” (Andile, FGD, young women, In other contexts, when parents take the child Mpophomeni) to the clinic this takes over the child’s decision- making power and autonomy and it could be Those who held contradictory views believed interpreted as bordering of parental psychological that parental involvement to this extent might control. This approach is not recommended inadvertently encourage early sexual activity. for its negative impact on children’s healthy However, this was dismissed by some who adjustment to young adulthood (Roman, Anja, & advocated for parental involvement. Donavon, 2012). However, given the challenges that young people sometimes faced with service “I also think that the correct way is that providers, perhaps this might help in this context if you go to the clinic, nurses should not to enable better access and young people might tell the child what the injection is for … feel confident to access these services when (they talk simultaneously). She should supported by their parents. just think of something else to tell the child as a nurse.” (Mbali, FGD, young There were contradictory views on the principle women, Mpophomeni) and the extent of involvement of parents in their children’s decision-making and use of A discussion about child discipline here, and SRH services. This was linked to parents being in all the other sites, evoked a discussion about permissive and thereby driving their children to children’s rights as an unwanted interference in have sex. Of course, participants’ views on this parenting. The main right that parents seemed to conflicted as well. be in disagreement with was the right to protection and dignity for children. It is against this right that “I would like to ask on the point where corporal punishment is deemed undesirable in parents accompany their kids … South Africa and child abuse is criminalised under does that not encourage kids to take the Corporal Punishment Act 33 of 1997, Section advantage and do as they please since 10 of the South African Schools Act 84 of 1996. they do family planning? Does that not However, one participant said that “these rights are encourage the child to go out there what’s killing us” (Sbongile), to which another asked: and have sex, because now mom has “How do rights kill you?” (FGD, Mpophomeni) granted me the right? She tells others that she has been taken to the clinic so At the same time parents in another FGD reported now she is free to do it?” (Zandile, FGD, feeling helpless. young women, Mpophomeni) “We have too much pressure because Others objected in defence of those parents. if you hit the child government will send you to jail, whereas I am the one “It is not because they mean to who feeds and pays for school fees encourage, but it is because they and everything, but if I get angry and notice the signs. Maybe a child has raise my hand, I’m the one who ends started on disappearing acts around up in prison and my child has rights in evenings, maybe they even go to bed my house. I do not know what is what without knowing where the child is and these days … we cannot do anything!” when she returns and asked where she (Woman 2, FGD, older women, Caluza) has been, she claims to have been playing at a friend’s house, and when This discussion was focused on corporal they confirm at that friend’s house they punishment. There was no agreement on this as point another friend’s house. So parents some participants were in favour of the legal ban

28 RESEARCH BRIEF 2 | JULY 2017 on corporal punishment whilst others felt that it “Sometimes we go to bed and have took away parents’ effective tools to discipline. sex in their presence and they watch while you have sex, and they try it out Media exposure, role-modelling and overcrowded just to see what happens. Growing up, living conditions were identified as challenges other children would take sticks and put and factors that influenced early sexual debut in them on their private parts just to see.” children. Participants who were parents also saw (Women 1, FGD, older women, Caluza) their responsibility for controlling media exposure. “These movies that we play, they watch them A similar concern was raised in the findings from while we are at work. Sometimes you play a movie the Flagstaff site. It is true that most children in that you are not supposed to watch with a six- South Africa tend to be raised by single parents, year and a seven-year-old child, all these [soap and single parents are predominantly reported operas] Generations, Bold and so forth. We as to be mothers (Roman et al., 2012). Despite the parents should not allow small children to watch challenges with space and not being married to movies. They shouldn’t watch because movies the father of one’s child(ren), there was a sense have age restrictions. They write at the bottom that parents should be responsible with their own according to age stages, sixteen and thirteen. So sexual expressions so as to afford their children we as parents must try a way, I don’t know how … good role-modelling. (all exclaim ‘mmm…’ silently).” (Women 1, FGD, older women, Caluza). “A parent must always have a way with children. I have so many boyfriends but “Okay, this thing about sex. I think it starts my children have never seen me with in watching sex scenes in [the American my boyfriends, so as a parent you must TV soap opera] The Bold and the Beautiful, be discreet and respect your children, and they know that having sex is the thing. because that also has an impact on And then they associate sex and love- children, so we as parents should hide making and take it is one thing, and they and respect our children. I am very think that the only way to show a person naughty, mawi. You know me—you have that you love them is by sleeping with seen me on the streets but not at home. them. So if it could start there on finding I stay alone in my room so even if my out what love is, that it is a package …” child knocks on my door at nine o’clock (Nu, FGD, young women, Imbali). in the night, I open freely.” (Women 2, FGD, older women, Caluza) It was not only exposure to sexual content in the media that worried parents but also exposure to These were also concerns raised by older adult’s sexual activities. participants, men and women, from Flagstaff. Parents in these Pietermaritzburg sites blamed “And since we live in one-bedroom themselves for following what participants houses and we have naughty habits. presented as modern diets which they believed Maybe you share the same bed with to be responsible for early sexual activity, diets your child and her father or maybe she for highly sexualised young people. sleeps on the floor. You might think she is snoring and then start having sex with “Yes, foods like cheese, eggs, foods we her father. She will be watching peeking were told not to eat when we were growing beneath the blankets and she watches up as young girls. A young girl was not everything that you do, and the way supposed to eat eggs and chicken. It is we talk … you speak vulgar language because our parents knew what it does in front of her she hears you … (and to a young girl, it makes you hot. Things the phones!) … and these phones we like Knorrox that the children eat, it is very buy them (yes, the phones, my sister).” hard, only God can help us …” (Women (Women 7, FGD, older women, Caluza) 7, FGD, older women, Caluza)

RESEARCH BRIEF 2 | JULY 2017 29 The myths around nutritious diet and sexual returned home her mother would say: initiation are reported in similar studies from ‘Do you have umgezaqolo?’ (meaning the same provinces (Ewing, Nduna, Rolston, & do you have a cleansing gift) (laughter). Khunou, 2013). And what will you learn if every time you return from a boyfriend, she is asked With all the difficulties that women believe about umgezaqolo? Yes, because you themselves to go through, when their daughters are were not home you need cleansing married off, they felt that they were short-changed. (laughter) … We went to her home and as we were approaching the gate, we saw “From the beginning the father will her standing by the door and shouted: blame me and say I am the cause of the ‘As you are coming to my house, do you situation. Then that’s when the problem have umgezaqolo?’ And I just laughed starts because when there are ilobolo …” (Nkuli) (FGD, young women, Imbali) negotiations he will get more cows and I “… which means you have to bring get only one (all agree). I don’t know how back a grocery pack. (Phill cuts in.) This we can change this because I am the one thing goes like this.” (Nu) (FGD, young who carries the foetus for nine months women, Imbali) and brings her up. I take care of her, I pay for school fees, look after her health This section highlights an important aspect of as she grows, and I do everything. And the challenges that parents experience with as soon as she engages to sex and gets communication about sexuality. The self-fulfilling pregnant I am the one who receives bad prophecy of black ignorance is alleged in a study words that I am the one who corrupted whereas white participants lamented this (Nduna & her. But comes a time for negotiations, he Mendes, 2010). In this case all the participants were gets more cows that me. When children black and their understanding of the challenges have ilobolo negotiations coming up they faced by their communities was also framed tell you straight in the face that they want within a similar discourse. This requires concerted their fathers and there is nothing you can interventions to dispel the stereotypes. do about that.” (Women 7, FGD, older women, Caluza) Sexual orientation and gender identity (SOGI) The discussion about sexual orientation (SO) and Parents’ negative influence on their children, gender identity (GI) arose spontaneously in most as well as their deliberate obliviousness to their interviews. With regards to same-sex relationships children’s risky behaviours, was condemned. and sexual orientation, here, as in Flagstaff, there Some parents were reported to act in ways that was an acknowledgement that it was difficult for encouraged risky behaviours. parents to know how to respond when one of their children came out about their homosexual “If she has got the sugar daddy who sexual orientation. Participants expressed their gives her money instead of the five concerns about this. rands you give her, you cannot tell her to leave him, but at least try. There are “It is still unusual, I would not lie. At parents like that, who do not approve of times it is hard to accept the orientation relationships of their daughters and their of your child. We do not how we can partners if a boy does not work, and make it possible for us to accept or they choose partners for them even if it how we can teach our children in the means an older person, as long as he community to understand different has money.” (Phill) sexual orientations, because you find “Some parents are just happy they get that at times the children get confused plastics (referring to groceries).” (Thuli) about these things and sometimes they stare and laugh if they see a gay person. “I have a friend who is a gelempisi We do not know how we can sit them (meaning she doesn’t have morals) down and talk to them and tell them that Enhle knows her, every time when she

30 RESEARCH BRIEF 2 | JULY 2017 we are not different at all. It is just our could take this opportunity and strengthen its choices of lifestyles that are different.” awareness-raising and education projects to (Woman 1, FGD, older women, Caluza) the heterosexual and cisgender community. Interventions need to go beyond raising “Maybe if there could be things like awareness and education to empowering parents workshops and awareness programmes with the skills needed to deal with their child who to teach us parents about these things, comes out and the society’s reactions to that. because it is us parents that have a problem. If we see that our children are “As parents we need to be taught not like others we hide them.” (Woman about these things … to understand 2, FGD, older women, Caluza) and maybe for us to know about their feelings and we could also teach them, Another participant concurred that great because actually this matter is still hard knowledge built understanding and tolerance. to understand. We should be the first ones as parents to understand their “Actually what has opened our minds feelings. When a girl child explains that in this ward … because as parents we she is a girl but loves other girls, you did not understand this thing … at times shouldn’t shout or hit her but sit her when you saw a boy walking funny you down and have a talk about it.” (Woman would say: ‘Ah! there is a faggot!’ But 1, FGD, older women, Caluza) then due to workshops that were held here in this ward by gay people, in In this study, sexual orientation was problematised time we got to understand how this gay by some participants and seen as needing a thing comes about. So actually it is the solution in the form of divine intervention. Zama workshops about LGBTIs that helped impressed on her fellow participants that divine us because we could not understand intervention would not help. when you saw a child walking funny you would use all these unsuitable names. There ensued some confusion about sexual So now we see them at a very young orientation and intersex. Participants from Caluza age … how they conduct themselves. questioned whether a lesbian could have periods. You can tell as a parent what they will Since she is seen to be acting like a boy, perhaps become. But if my child has a baby then she did not have her periods, they said. later decides to change her sexuality, she would rather leave my house, One woman asked if “they place it [the pad] in leave! I cannot wash panties whereas both private parts” (Woman 1, FGD, older women, I knew her previous sexuality. Now in Caluza). This led to a discussion and argument this ward we have learned how it works, about whether there were people born with both with sangomas [Zulu traditional healers/ male and female reproductive organs. Some diviners], blah blah blah. We have believed yes and others no. Zama herself, who knowledge now like I even have friends was knowledgeable about lesbianism, denied who are gay in my neighbourhood and that intersex persons existed. sometimes when people see me walking with them they would say: ‘What is that Homosexual relationships were partly accepted. walking with mawi?’ That is because There were misunderstandings of bisexuality as they do not have the knowledge that I a legitimate form of sexual orientation. On the have. Because of my knowledge, I treat theme of relationships, lack of understanding of them as my own children.” (Woman 3, fluidity and variations in sexual orientation and FGD, older women, Caluza) gender identity seemed to create confusion and misunderstanding. Notably, there was a strong These debates from the participants suggest negative reaction to what some participants saw that there was willingness to learn and embrace as ‘switching’ of sexual orientation, from straight diversity. The GLN (Gay and Lesbian Network) to gay. People who have had heterosexual

RESEARCH BRIEF 2 | JULY 2017 31 relationships and were later in homosexual Hence, some choose to hide their real sexual relationships were misunderstood and dismissed. identities, suppress their attraction to same-sex In one FGD an unidentified voice shouted, “It’s a persons until they feel safe to disclose it, and very bad thing [when] you know someone as a thus risk being seen as living ‘bisexual’ lives or boy and then suddenly he is a girl!” Another said: changed lifestyles. “First you have a child then suddenly you become a lesbian, how?” (Woman 6, FGD, older women, There were different sets of information and beliefs Maswazini). Another woman in the Caluza FGD held by different participants. These went hand spoke the difficulties people have with people in hand with multiple hypotheses about sexual who ‘change’ their sexual orientation. identity and sexual orientation. Among these was the view that people are socialised into being gay “Here at ward 20, we live with them and and that their sexual orientation can change. we accept them and we take them as our own children. When we call them, “I have a gay brother … and I told him they respond ‘Ma’. However, the ones to drop this thing and he agreed to but that we do not like are the ones that have he hasn’t stopped. He acts as if he has children and then suddenly decide to be wings when he walks down the street. You homosexual. We do not like those. We should see him! (Participants all laugh and want the ones that grew up not hiding some mumble inaudible words).” (Andile, their sexuality because as parents they FGD, young women, Maswazini) grow right before our eyes. We see the way they act and the way they do things. This belief that one can ‘drop’ being gay can It is obvious to see. When boys play, dangerously fuel the misconception that people you can tell when a boy child does not are ‘recruited’ or choose to be gay. This discussion want to play with them but would rather created opportunities for unlearning of old play with girls and play with dolls. We knowledge and learning new information, based welcome them with our open arms a on evidence that could lead to attitude shifts. This hundred per cent. is one advantage of the FGD as a data-collection method. References to the bible and a curse Here in our ward no one can say they were also made here, as in Flagstaff. However, have experienced ill treatment or abuse there was less gay-bashing and no reference to because they are misunderstood. We homosexuality as being un-African at all. do not like people who change after having a child. We do not like people “We will not judge them much because like that, who decide to change their when another person grows up, sometimes identity (someone who has children they have this thing that you know you are and then comes out as gay) … She is a woman but sometimes wish to associate hurting herself and her children as well, with men. They get that feeling that you because the child will become a joke just wish to act like a man.” (Woman 12, amongst other children at school. They FGD, young women, Maswazini) knew a child’s mother as a woman and then suddenly she is a guy and loves Explanations of why people ‘turned lesbian’ were another woman?” (Woman 7, FGD, older used to justified the ‘deviance’. It was reported that women, Caluza) women’s disappointment in relationships with men resulted in lack of interest in men. In an attempt to This discourse, that assumes that people make sense of this some participants said: ‘suddenly decide to be homosexual’, ignores the fact that for a long time sexualities that are “A woman has much more love to give not heterosexual have been marginalised. In than a man. They sometimes seek love South Africa, homosexuality was decriminalised from other women because of suffering only in 1996 (Croucher, 2002). Despite the too much from men or maybe she is decriminalisation there is still a lot of intolerance tired of men.” (Balungile) and abuse towards lesbians and gay people.

32 RESEARCH BRIEF 2 | JULY 2017 “Listen, you know what causes women more focused on men because I am a to change their sexuality? (Others woman and I did not carry on.”(Khetiwe, agree, eager to know.) It is the treatment FGD, young women, Maswazini) they get from men. When people decide to be gay they do not hide that they are Societal expectations of men and women based in love, unlike you when you love a man on sex, gender and one’s gender identities and you show him that you really love him roles informed some of these discussions. but at some stage he will retract and goes and dates someone else. But gays “In Greytown there is a person who is have no problem when they are in love. a lesbian. She is a woman. She has They show each other that they are in breasts and everything … so she moved love (some of them laugh).” (Woman12) to Pietermaritzburg to work. She worked with us in Richmond and she dated “She is right, gays have no problem, and women but when you looked at her, there they do not have any troubles.” (Woman6) was nothing manly about her. She even (FGD, young women, Emaswazini) had a soft voice. No, she was a woman trying to be a man. She has breasts like There was also recognition that lack of social yours. She even has her periods.” (Gugu) acceptance might force others to live in the closet “So would we say that is natural or she and subject themselves to family pressures. changed?” (Slindile)

“Maybe that is not the kind of life he wants “Some fake it. I would say she was a fake to lead. Maybe he is gay but he lives that because where she grew up, she was other life because he wants to please the treated as a female. They even called family. They pressure him into getting Sis’Yenzo, but when she got this side, she married, so he is looking for a hideaway is a male (chuckle). She grabs women and (interjection: no, he also wants to be with dates women, does all sorts of things.” a woman). That is why there are people (Gugu) (FGD, young women, Emaswazini) called after-nines: at night they date men The focus in this example is on one and during the day they date women person dating women and takes away (interjection: there are after nines? No, the involvement of her female partners they are just selfish there is no such thing. as lesbian as well, and thus proving This sort of thing exists]. It’s wrong if they the existence of a lesbian community tell children to call them fathers. They are rather than exceptionalising ‘her’. In this feeding children wrong things, but other view, only a male-bodied person should than that this sort of thing exists. People date a woman. The idea of a woman who do it all, they have sex in every way. dating another woman destabilises this No, that is wrong. It is just being bitchy. heteronormative order. As such, that No, they are generous. They never say no female is seen to be ‘trying to be a man’. to anyone. They are generous.” (Zama, FGD, older women, Caluza) Even normative dating activities, such as sharing gifts, were questioned in lesbian relationships, One of the participants shared proudly that she as if these should not be happening. Gugu had twice dated a woman. Asked if her sexuality expressed shock that “in a workplace they will was “mixed”, she said: even buy each other gifts” (FGD, young women, Maswazini). This statement seemed to suggest “No, that is never the case at all (they all that there are different expectations of people in laugh and exclaim ‘Ha!’). You take it as a same-sex relationships: they are not entitled to joke but your partner … you can see that the heterosexual ways of courting. they are serious because even when I bump into her in town I can see that she A discussion of positive aspects of being gay is still a boy, but then my feelings are ensued and some of these were contested.

RESEARCH BRIEF 2 | JULY 2017 33 These were about safety against pregnancy, … you would [explain] that you want to safety against HIV (for lesbians) and abuse-free sleep with your partner but you have piles. relationships. One participant said: “It is good Since a nurse has to see the problem a man dates another man and a woman dates first before treating you, you see that you another woman. They lead a good life and they cannot just walk in the nurses’ room and have each other unlike us … we get abused” show your bottoms and your piles. You try (Women 13, FGD, young women, Maswazini). other means first … maybe lower certain foods or apply an ointment, maybe try the It was evident in these findings that homophobic help of someone who has had that same attitudes from clinic staff interfered with access to problem before. Maybe if clinics and reproductive health. hospitals could appoint an individual to look out for gays and lesbians, someone “Yes, say you are a [butch] lesbian, with an understanding of homosexual you cannot go the clinic and say you lifestyle … maybe they can take a look at want contraceptives because nurses you first, maybe even take pictures and are getting a picture of a boy. They can then go to show them to a nurse so that see that it is a girl, but leading a boy the nurse can see what kind of sickness lifestyle, and if you go there looking you are contracting. She may even tell if for contraceptives they get confused: you do not have piles … maybe you went that how does it happen? What do you rough on the sex … that would be better.” need it for? Then that leads to people (Zama, FGD, older women, Caluza) being scared to go to clinics because of judgements they face, and in gay people In this example the client could be bisexual, and we as well. If they have piles they fear going learnt how bisexuality is frowned upon and the least to clinics and have to show nurses, understood in this community. Clinic staff attitudes because in the clinics they don’t have need to be changed through consistent and homosexual nurses who are supposed repeated training to encourage health-service use to attend to homosexuals only. A nurse by affected and especially minority communities.

34 RESEARCH BRIEF 2 | JULY 2017 4. CONCLUSIONS from the general community, for instance, the conditional acceptance of gay people. This study aimed at exploring the views, perceptions and experiences of the community Longstanding worries about body-shape changes with regards to SRHR. These views and as a result of use of hormonal contraceptive experiences are assumed to influence access to were also expressed here. This means that SRHR services. These findings confirm that views more education about this is needed so that and experiences reported by the participants are people come to know the effects of pubertal greatly shaped by and intertwined with cultural changes versus side-effects of contraceptives, and religious beliefs. Inequity in terms of access two phenomena usually experienced at the same and experience was related to lack of uniform time. The popularity of the ‘barcode’, referring to access to sexuality education and differences implants, as well as the concerns about its side- in application of service norms and standards. effects, cannot be ignored. While the basic education Life Orientation school subject offers some lessons on SRHR, the delivery Gender-power inequality meant that women is sub-optimum, leaving many young people who could not express their concerns in fear of pass through the school system ill-equipped in infuriating men or ‘causing him to be violent’. Chief the attainment of these rights. amongst causes of relationship conflict was that women should not make men wait to have sex Across the greater Pietermaritzburg sites, if they do not want to lose them, otherwise they there were challenges related to pregnancy will go somewhere else to get sex. A perception and paternal acknowledgement. There was an that relationships should be transactional was assumption that people who drank in taverns harboured by parents as well, who found it were more at risk of sexually transmitted HIV appropriate for their children to date a partner infection. Whilst there is a grain of truth in this, who would provide them with money. it should not create a sense of invincibility for women who do not visit taverns regularly, or fuel A different take on race relations is needed in the stigma and a ‘deserving victim’ label for women media, as media tends to portray white families who drink alcohol. as being able to deal better with communicating about relationships with children. The perceptions The need for a variety of condoms to be publicly that black people do not know how to deal with available, the demand for flavoured condoms these was juxtaposed with ‘perfect’ white families, and for female condoms should be addressed. where there is a mother and a father. Where there This research proves that contextual factors was recognition of challenges with absent fathers are important in facilitating more education on in the black community, this was regarded as part condom use with the aim of increasing condom- of the reason why parent-child communication use efficacy. Marriage and intimate partner about sexuality was lacking. Black parents were violence seemed to be the main barriers to said to express love through shouting, while condom use. white people were reported to employ open and effective communication. Even when black There was subtle homophobia expressed by parents wanted to talk, they did not know when to nurses, as reported by the participants. For start conversations with their children. This was instance, it was deemed homophobic for nurses coupled with the perception that black people to ask a lesbian client about her male partner were not knowledgeable, attributing ignorance to when it is known in the community and the clinic being black or African, rather than to a lack of that she is a lesbian. This was experienced by access to IEC about SRHR. those affected as rude and insensitive. There was also evidence of ‘progressive’ homophobia

RESEARCH BRIEF 2 | JULY 2017 35 5. RECOMMENDATIONS Parents will need additional support with addressing aspects such as Choice of SRHR education The interventions should focus on educating the Termination of Pregnancy (cToP), homosexuality community about STIs, including dispelling myths and condom use, as these seemed to be rather about condom lubrication being a prophylaxis difficult subjects for them. against STIs. Challenging stigma, stereotypes and social behaviour Advocacy for the female condom, dentals dams, Stigma and discrimination against HIV appeared lubricants and other commodities needed for to influence status non-disclosure and these safer sex for LGBT-identifying persons is needed. need to be addressed. Alcohol was identified as Information needs to be made available in local a driver of HIV and GBV. languages, hence, the need to develop local language competency in translating scientific Interventions aimed at responsible drinking, as jargon to simple indigenous languages for well as debunking gender stereotypes around education purposes. alcohol drinking, would be useful. The same may go a long way in addressing HIV stigma, Given that most South Africans, despite of especially for women who drink alcohol as they the rural/urban divide, have access to radio seem to be subjected to multiple forms of stigma. and television, it is worth advocating for more appealing programmes on SRHR to be aired, Access to contraceptives especially during prime time. Access to SRH services and in particular the choice of contraceptives needs to be increased through Parent-child communication (PCC) youth-friendly clinics that are adequately stocked. Socialisation, in particular role-modelling and communication, was reported to have an Autonomy and agency, especially for young influence on young people. people, needs to be fostered.

Adults need to be supported in these and Intersections of cultural norms and socio- communication should be directed at both males economic realities should be addressed in SRHR and females. interventions.

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RESEARCH BRIEF 2 | JULY 2017 39 University of the Witwatersrand Sexual & Reproductive Health Rights Programme 1 Jan Smuts Avenue AIDS Foundation of South Africa Braamfontein 2000 135 Musgrave Road Johannesburg, South Africa Durban 4062 http://www.wits.ac.za http://www.sexrightsafrica.net