Gender Violence:The Health Impact – Sexual Assualt, HIV/AIDS & Other STIs

by Jaya Shreedhar

It’s been a good many years, but I remember the waving fields of wheat, the distant bleating of goats and the pungent fragrance of dung at the entrance to Shama Devi’s mud-and- thatch dwelling in Uttar Pradesh. The year is 2005 and Shama, a mother of four, made a brisk living tending to her cows and hens, working the fields for daily wages and scraping together enough to feed her children and herself and even offer a visitor a glass of tea and a couple of biscuits. Not bad for a wisp of a woman, whose crinkled eyes spoke of hours in the sun and at her chula.  Shama was living with HIV. The doctors had tested her when she “went for a health check-up in her third month of pregnancy and now, her infant is due for an HIV test”, she whispers. Kishen, her husband, still sold fruits on the streets of Surat as he had for the past nine years and visits her twice a year. He had tested positive for HIV two years ago. “He got it from women,” Shama adds. “What’s a man to do, with daily earnings burning a hole in his pocket and a body that aches from pushing a heavy cart all day on pitiless streets?”  What indeed.  The National AIDS Control Organization estimated about 2 out of every two dozen female sex workers in the country to be HIV positive at the time, with migrant workers like Kishen forming a huge percentage of their clientele. Over 8% of male migrant workers in India are estimated to be HIV positive. What chance did the Shama Devis have?   Most married women with HIV or STIs continue to be infected by their husbands.  Studies among HIV discordant African couples show that uninfected wives who report sexual violence are more likely to get infected.  Many like Shama Devi, accept their ill health as a matter of course. Few if any, have grouped together to discuss their vulnerabilities or their options for self protection.

Female Sex Workers, a more marginalized and disempowered community took that essential step. The Durbar  Mahila Samanwaya Committee, the country’s first registered co operative society for and by sex workers, went door to door talking about HIV and condoms  in Kolkata’s sprawling red light district of Sonagachi, and negotiated sex workers rights to health information, health care and safe working conditions as crucial to HIV prevention efforts.  Whether a woman’s body may be legitimately traded for cash or goods, and whether that will reduce the occupational hazards of sex work and prevent trafficking and abuse of girls and children is debatable. But the unionization of sex workers served to bring the vulnerability of women to HIV out into the open and catalyzed discussions on rights based approaches to HIV prevention. Female Sex Workers continue to bear a disproportionately high percentage of HIV infections, at an estimated 2.67%.

HIV, Sexually Transmitted Infections, unwanted pregnancies, psychological trauma and chronic vulnerability to ill health are the flip side of the coin of sexual disrespect/violence. The connections are deep and varied, spanning biological and socio-cultural aspects.

The biological connect is direct and easily recognized. Women are physically more at risk of contracting HIV/STIs. Being the receptive partner in sexual intercourse, they receive a larger inoculum of HIV or other infectious agents into their bodies from ejaculated semen and seminal fluid while the vaginal fluids are much less in volume and capacity to infect. The mucosal surface of the vagina offers a larger absorptive surface for pathogens than does the penis. In sexually violent acts such as vaginal or anal rape, particularly among girl children, adolescents and teens, the tender mucosal surfaces may suffer abrasions and tears that serve as gateways for the easy access of STI pathogens and HIV into the blood stream.

In addition to these immediate and direct outcomes, there are studies indicating that the long term risk of acquiring HIV is higher among rape survivors and victims of sexual abuse in childhood.

The third National Family Health Survey found that one in ten married women between the ages of 15 to 49 years suffered sexual violence at the hands of the husband. Contrast that with the finding that only 1 percent of married women had ever initiated violence of any sort against their husband.

On the one hand, the trauma of sexual violence wreaked on oneself by someone who is deemed as protector and provider; on the other, societal and cultural coercion to derecognize the trauma as not trauma at all, but a woman’s normal state of being.  Apprehensions of spousal/partner rape and violence inhibit women from seeking information and health care that can protect them from HIV/STIs, leave alone negotiate condom use.

Structural approaches that reduce the risk of violence in sex, whether marital or transactional and that protect the rights of women, sex workers or otherwise, are critical to the success of HIV prevention. What continues to be missing from the discourse is initiatives for men, particularly perpetrators of physical and sexual violence, that helps them access a better understanding of the roots of violent behavior and its fall out, and interventions that can help them restructure their own perceptions of what male dignity and gender respect mean.

The evidence is clear. Over twenty five years of AIDS interventions in India by health workers and activists show that preventing the spread of HIV and STIs is all about putting the rights of the most vulnerable – particularly women’s rights – first.

References

1. National Family Health Survey 3 (2005-6)
2. MC Public Health.2010 Aug 11;10:476. doi: 10.1186/1471-2458-10-476. Violence against female sex workers in Karnataka state, south India: impact on health, and reductions in violence following an intervention program. Beattie TS¹, Bhattacharjee P, Ramesh BM, Gurnani V, Anthony J, Isac S, Mohan HL, Ramakrishnan A, Wheeler T, Bradley J, Blanchard JF, Moses S.
3. HIV Sentinel Surveillance –A Technical Brief, 2012-13 The National AIDS Control Organization http://naco.gov.in/upload/NACP%20-%20IV/HSS%20TECHNICAL%20BRIEF/HIV%20Sentinel%20Surveillance%20Technical%20Brief.pdf

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Dr Jaya Shreedhar is a journalist and medical doctor based in Chennai. She currently works as an independent health communications consultant and teaches Health Journalism at the Asian College of Journalism.