Vaginal drying and scarification have been reported as possible risk factors. Published research on the former has been confined to East and Middle Africa. This paper reports on research in West Africa employing a survey of 1,976 females in southwest Nigeria, where they reported on their own vaginal drying, the scarification of their sons, and their participation in blood oaths. It was concluded that vaginal drying is not a risk-factor for AIDS in southwest Nigeria, and probably more broadly in West Africa, that scarification may be in the few cases when group scarification is practised, and that the practice of blood oaths probably puts those involved in danger

Caldwell, John C

Caldwell, Pat

Orubuloye, I. O

The Australian National University

Health Transition Review, Supplement to Volume 5, 1995, 161-165A note on suspect practices duringthe AIDS epidemic: vaginal dryingand scarification in southwestNigeria *I.O. Orubuloyea, Pat Caldwellb and John C. Caldwellba Centre for Population and Health Research, Ondo State University, Ado-Ekiti, Nigeria.b Health Transition Centre, National Centre for Epidemiology and Population Health,Australian National University, Canberra.AbstractVaginal drying and scarification have been reported as possible risk factors. Publishedresearch on the former has been confined to East and Middle Africa. This paper reports onresearch in West Africa employing a survey of 1,976 females in southwest Nigeria, wherethey reported on their own vaginal drying, the scarification of their sons, and theirparticipation in blood oaths. It was concluded that vaginal drying is not a risk-factor forAIDS in southwest Nigeria, and probably more broadly in West Africa, that scarificationmay be in the few cases when group scarification is practised, and that the practice of bloodoaths probably puts those involved in danger.The severity of the sub-Saharan Africa AIDS epidemic has led to a search in the region forcultural practices that might facilitate the transmission of HIV either through rendering thevaginal wall thinner or damaged or by breaking the body's skin in such a way as to make theexchange of blood more likely.Research on vaginal drying has mostly been reported for East, Southern and MiddleAfrica, while there has been only limited reporting of scarification and similar practices. Thisnote adds to the information available by reporting on Southwest Nigeria.The Southwest Nigerian studyThe opportunity was taken to add questions to a large study in Southwest Nigeria on relatedmatters pertinent to AIDS: male sexual behaviour (Orubuloye, Caldwell and Caldwell1995a,b), and male and female circumcision (Caldwell, Orubuloye and Caldwell 1995c). Thequestions reported here were asked only of female respondents.A sample survey, with some in-depth questions, was conducted in 1994-95 in threepredominantly Yoruba states of Southwest Nigeria, Ondo State, Oyo State and Lagos State.In each, one urban area was sampled, Ado Ekiti, Ibadan and Badagry respectively. Becauseof the very limited rural population in Lagos State, rural surveys were only carried out inOndo State, where the Ekiti West and Ekiti Southwest Local Government Areas weresampled and in Oyo State where Egbeda Local Government Area was chosen. A total of                                                * In Canberra, the authors were assisted by Wendy Cosford, Pat Goodall, Jacob Oni and Ron D'Souza;   in Nigeria, by Toyin Sadiq and Kemi Oguntimehin162 Orubuloye, Caldwell  and CaldwellSupplement to Health Transition Review Volume 5, 19951,749 males and 1,976 females were interviewed, although only the latter are reported uponhere.The towns and rural areas chosen were selected so as to examine change. Both the townsand the local government areas chosen have an unusually high level of educationalinstitutions even for this advanced part of the country. The female respondents were 88 percent Yoruba with an average age around 35 years. Just over half had experienced somesecondary education and most of these women worked in the non-traditional sector of theeconomy. However, 54 per cent were either farmers or traders. Almost 70 per cent wereChristian, 30 per cent Muslim, and only one per cent described themselves as being adherentsof the traditional religion. In terms of marital status, 24 per cent were not in a union at thetime of the survey, 45 per cent were in monogamous marriages and 31 per cent were inpolygynous ones. This level of polygyny, namely 41 per cent of currently married womenhaving co-wives, is typical of the area and of much of West Africa. In terms of ethnicity andreligion the sample approximated census and survey counts.Vaginal drying and tighteningVaginal drying and tightening has been widely reported in East, Southern and Middle Africa(Brown, Ayowa and Brown 1993; Runganga, Pitts and McMaster 1992; Caldwell andCaldwell 1993:829-832). Its most common purpose has been reported to be the malepreference for such drying before sexual intercourse. It is probable that a high level of genitalinfections is the primary cause of vaginal wetness, and high parities cause vaginal looseness.AIDS researchers became interested in vaginal drying when it was established that substanceswere used which might change the vaginal mucosa and that leaves, rags and other abrasivematerials were used for cleaning in such a way that the vaginal wall might be scratched. Onecommon drying agent was the astringent, alum, which is widely used in the West for dryingthe blood produced by shaving cuts. Since the Nigerian research was undertaken a study hasbeen reported of 329 women attending an STD clinic in Lusaka, Zambia (Sandala et al.1995). Fifty-eight per cent were seropositive, one-third pushed cloths or leaves into theirvaginas for drying and one-tenth of this group had swollen or peeling vaginal surfaces as aresult, but no association could be shown between drying and infection with AIDS.In the Southwest Nigerian study nearly all women reported that they cleaned and driedtheir vaginas before sexual activity, but none that they used tightening agents. The cleaningwas largely external and there was very little internal douching. They reported that thecleansing was needed to prevent infection resulting from intercourse and to reduce the levelof vaginal odour. The emphasis on reducing odour rose with education and other socio-economic indices and was greater in urban areas. This presumably demonstrated both greaterfastidiousness and easier access to piped water and other facilities. Nevertheless, it may alsohave shown that these women were more sceptical of the thesis that such cleaning and dryingcould protect them from infection.Nearly all the elite and most urban women said that the cleaning and drying was for thebenefit of both sexual partners. In rural areas, one-third of women said that they carried outthese procedures only for the benefit of their male partners and to meet their demands. This isevidence of a situation which is clearly passing but where not long ago the male demand wasparamount. Nine out of ten men in both urban and rural areas, with little socio-economicdifferentiation, still expect such cleaning. When asked what happened if the husbands knewor suspected that such cleaning had not been done only one-tenth of the female respondentssaid that sexual intercourse would go straight ahead. One-third said that their male partnerwould just give up the idea of having sex at that time, while the rest reported that he wouldscold them and tell them to clean themselves. Husbands were less likely to make suchcomplaints or to terminate sexual activity among the urban elite but this probablyVaginal drying and scarification in southwest Nigeria 163Supplement to Health Transition Review Volume 5, 1995demonstrates little more than lower levels of vaginal infection and higher levels of vaginalhygiene among their wives or other female companions.The major finding in this study is set out in Table 1. That finding is that there is verylittle use of harmful substances or objects in the washing and drying. A few rural women douse cloth and this might scratch or might not be clean. But there is no parallel to thedangerous cleaning methods reported for other parts of Africa. It is possible that theSouthwest Nigerian pattern is widespread in West Africa and that this accounts for the lack ofWest African research reports on the matter. Possibly there is some cause for concern amongthe one-sixth of women who report employing antiseptic solutions, especially as most ofthem do so two or three times a day. More generally, there may be concern for the higherfrequency of internal washing practised by these women.Table 1Vaginal cleaning and drying (1,976 female respondents)Urban respondents(N=1,073)Rural respondents(N=903)Frequency of cleaning and drying (%)Rarely or not regularly 8 6Once daily 27 25Twice daily 45 39Three times daily 5 15More often 15 15Methods of cleaning (%)Soap and water 63 50Antiseptic solution 16 12Water only 9 18Vaginal cream 1 2Other (cloth etc) 1 3No response 2 9Does not clean regularly 8 6Total 100 100Once these matters would have been taught as a preparation for marriage, usuallyformally as part of puberty rituals. Nowadays, half the women claim to have been given noinstruction but to have followed their own commonsense. Nearly all the rest were instructedby parents or relatives, mostly the former in towns, while in rural areas, where there is still aconcept of the appropriate relatives for such a task (maternal grandmothers or aunts usually),two-fifths of the instruction was given by other relatives.ScarificationScarification is making incisions in the skin. Traditionally for protective purposes, it wasuniversal among Yoruba males of southwest Nigeria. This is still generally true, for, amongrespondents whose children were regarded as old enough for scarification, 95 per cent ofparents had had it performed.Scarification can lead to very considerable bleeding, and has aroused the interest ofAIDS researchers especially when group scarification takes place using the same instrument.Perhaps the most interesting finding from the research was the evidence that scarificationwas showing little sign of decline. This was established partly by the continuing high level ofthe practice and partly by the almost complete lack of socio-economic differentials in its164 Orubuloye, Caldwell  and CaldwellSupplement to Health Transition Review Volume 5, 1995practice. The only differences — and these were not statistically significant — were thatevery adherent of traditional religion carried out the practice, and that only 93 per cent of thesecondary educated urban elite under 35 years of age had carried it out compared with 96 percent of the rest of the population.Scarification is almost entirely practised for protection from disease, ill-fortune orwitchcraft and other evil forces. Nearly all rural respondents answered immediately in theseterms, as did 92 per cent of the urban respondents. The remaining eight per cent claim to do itsimply because it is cultural or traditional.The key responses which indicate whether scarification could increase the risk of HIVtransmission are given in Table 2.Table 2Scarification of sons (1,425 mothers of sons who have reached the suitable age)Urban RuralWhen was it carried out? (%)Before going to school 8 16Before going to new places 5 5At festivals 11 6When needed or there is a divine sign 9 17No particular time, no response 67 56100 100Who did the scarification? (%)Traditional specialist 8 22Traditional doctor 32 21Other healersa 52 50Others (relatives etc) 8 7Total 100 100aHerbalists and some persons claiming contact with the modern health system (nurses, dispensers etc.)There are several important findings in Table 2. The first is that less than one-tenth ofscarification is now associated with festivals or rituals, a situation which must reduce thechance of rapid, successive scarification. The second is that there is probably still asubstantial amount of scarification done to meet crises, and this could well mean more thanone family member being done at the same time with a raised risk of intra-family HIVtransmission.The medicalization of traditional practices, which we have already reported in the case ofcircumcision (Caldwell, Orubuloye and Caldwell 1995), may also be taking place to a limitedextent with scarification. Many of these procedures are now carried out by persons claimingcontact with the modern health system, some presumably in hygienic conditions and with thesterilization of instruments. Three-quarters of the scarifications performed on the sons of themodern, urban elite are done in this way. The danger of group scarification is presumablylargely confined to traditional practitioners.Blood oathsSolemn agreements were signified in the days before written documents by the participantscutting themselves and sucking each other’s blood. Clearly the risk of HIV transmissionwould be high when people had cut lips or mouth sores. We heard persistently that such oathswere still performed and accordingly we directed questions to the practice. The oathsVaginal drying and scarification in southwest Nigeria 165Supplement to Health Transition Review Volume 5, 1995increasingly became part of the initiation ceremonies of secret cults and of criminalorganizations. They are practised among secret societies in universities and schools and suchsocieties are becoming more numerous.Surprisingly, eight per cent of rural respondents and five per cent of urban respondentsreported that they had participated in at least one contract of this type, and the levels wereprobably higher among their husbands. Participation appeared to decline with urban residenceand steeply with education and other socio-economic indices but as the cults require an oathof secrecy this information must be suspect. As a form of agreement it remains mainly apractice of the illiterate and is their form of documentation. The scars remain. In additionthere is a religious element in that this ritualistic agreement is made in a way that is noted bythe ancestors and the gods.SummaryIn Southwest Nigeria, vaginal cleaning and drying is of a type that is unlikely to augment theAIDS epidemic. There is no vaginal tightening. In contrast, scarification on the existing scalemust present some danger. This statement should be qualified by noting that the proportion ofgroup scarifications is probably small, and that half of all scarification is now carried out inthe modern medical sector. Blood oaths are still practised by some people, and would appearto be exceedingly dangerous in terms of potential HIV transmission.ReferencesBrown, Judith E., Okako Bibi Ayowa and Richard C. Brown. 1993. Dry and tight: sexual practices andpotential AIDS risk in Zaire. Social Science and Medicine 37,8:989-994.Caldwell, John C. and Pat Caldwell. 1993. The nature and limits of the sub-Saharan Africa AIDSepidemic: evidence from geographic and other patterns. Population and Development Review 19,4:817-848.Caldwell, John C., I.O. Orubuloye and Pat Caldwell. 1995. Male and female circumcision in Africa:from a regional to a specific Nigerian examination. Mimeograph. Health Transition Centre,Australian National University.Orubuloye, I.O., John C. Caldwell and Pat Caldwell. 1995a. The cultural, social and attitudinal contextof male sexual behaviour in urban south-west Nigeria. Health Transition Review 5,1:207-222.Orubuloye, I.O., John C. Caldwell and Pat Caldwell. 1995b. Perceived male sexual needs and malesexual behaviour in southwest Nigeria. Mimeograph. Health Transition Centre, Australian NationalUniversity.Runganga, Agnes, Marian Pitts and John McMaster. 1992. The use of herbal and other agents toenhance sexual experience. Social Science and Medicine 35:1037-1042.Sandala, Luciano, Peter Lurie, M. Rosemary Sunkutu, Edgar M. Chani, Esther S. Hudes and NormanHearst. 1995. 'Dry sex' and HIV infection among women attending a sexually transmitted diseaseclinic in Lusaka, Zambia. AIDS 9, supplement 1:S61- S68.

A note on suspect practices during the AIDS epidemic: vaginal drying and scarification in southwest Nigeria

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A note on suspect practices during the AIDS epidemic: vaginal drying and scarification in southwest Nigeria

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