This ethnographic research among rural South African men and women seeking care for STDs explores constraints to communication among partners and defines predominant patterns of sexual networking. A series of fifteen open-ended interviews explored topics related to sexual networking and partner communication. Patterns of sexual networking showed clear gender variation, with men more likely to discuss multiple partners. Both men and women believed they should tell one partner about their STD, most often a steady partner. Strong distinctions were made between regular and casual partners, with an emphasis on the role of trust in a steady relationship. Men and women expressed anxiety about telling their partners of their illness, but women more often expressed fear whereas men felt embarrassed. Multi-partnered sexuality is common and is widely accepted for men. While the importance of regular partnerships is clear for both men and women, sexual relationships appear to be highly unstable. Communication among partners could be facilitated by stronger health promotion messages, such as the importance of telling a partner about an STD. Prevailing patterns of communication and sexual networking have profound implications for the STD epidemic

Harrison, Abigail

Lurie, Mark

Wilkinson, Nomsa

The Australian National University

Health Transition Review, Supplement 3 to Volume 7, 1997, 103-107Exploring partner communication andpatterns of sexual networking: qualitativeresearch to improve management of sexuallytransmitted diseasesAbigail Harrisona, Mark Lurieb and Nomsa Wilkinsonca Centre for Epidemiological Research in Southern Africa (CERSA), Medical ResearchCouncil, Hlabisa, KwaZulu/Natal, South Africab Hlabisa Hospital, Hlabisa, KwaZulu/Natal, South Africac Johns Hopkins University,School of Hygiene and Public Health, Baltimore MD, USAAbstractThis ethnographic research among rural South African men and women seeking care for STDsexplores constraints to communication among partners and defines predominant patterns ofsexual networking. A series of fifteen open-ended interviews explored topics related to sexualnetworking and partner communication. Patterns of sexual networking showed clear gendervariation, with men more likely to discuss multiple partners. Both men and women believed theyshould tell one partner about their STD, most often a steady partner. Strong distinctions weremade between regular and casual partners, with an emphasis on the role of trust in a steadyrelationship. Men and women expressed anxiety about telling their partners of their illness, butwomen more often expressed fear whereas men felt embarrassed. Multi-partnered sexuality iscommon and is widely accepted for men. While the importance of regular partnerships is clear forboth men and women, sexual relationships appear to be highly unstable. Communication amongpartners could be facilitated by stronger health promotion messages, such as the importance oftelling a partner about an STD. Prevailing patterns of communication and sexual networking haveprofound implications for the STD epidemic.This paper reports ethnographic research conducted in the Hlabisa district of northernKwaZulu/Natal, South Africa. The district is situated in the heart of a region populatedpredominantly by Zulu-speaking black South Africans. The area is rural, with a highproportion of men migrating to larger cities for work. This area is also at the centre of theAIDS epidemic in South Africa, with HIV prevalence among pregnant women in HlabisaDistrict calculated at 26 per cent, approximately twice the national average. Sexuallytransmitted diseases are epidemic: a recent study of women attending family planning clinicsin Hlabisa found that 52 per cent have at least one STD (Sturm et al. forthcoming).Studies throughout Sub-Saharan Africa confirm the importance of understanding thesocio-cultural factors that determine sexual behaviour, and of using such research to informthe design of feasible interventions (Standing 1992; Orubuloye, Caldwell and Caldwell 1993;Moses et al. 1994;). The purpose of this research was to inform the development of improvedstrategies for partner notification of patients diagnosed with an STD. In practice, many partnernotification programs fail to attract a significant percentage of partners, and thus fail toachieve the goal of reduced transmission of STDs (Winfield and Latif 1985; Faxelid et al.1994; Steen et al. 1996). A major reason for this may be failure to situate partner notificationwithin the prevailing social and cultural framework. This includes a failure to appreciateadequately the constraints to discussing sex and sexual activity with a partner, the ways inwhich partners communicate about issues related to sex, the extent to which different types ofA. Harrison, M. Lurie and N. WilkinsonSupplement 3 to Health Transition Review Volume 7, 1997104relationships exist and how partners are perceived in these relationships, and how patterns ofsexual networking develop.MethodsA series of fifteen open-ended, semi-structured interviews were conducted with men andwomen seeking care for STDs in the outpatient department of Hlabisa district hospital. Aresearch nurse interviewed consecutive patients about various aspects of their illness,including their partners. Key informants were identified from among these patients forparticipation in in-depth interviews, which focused on various aspects of partnercommunication and sexual networks.The interviews focused on the process of partner notification, and possible constraints tocarrying this out. Through this, the following topics related to sexual networking wereexplored:  numbers of partners, types of partners, type of partner most likely to be told aboutthe STD, and factors influencing notification of a partner. Topics explored in the area ofpartner communication were: barriers to communication about STDs, facilitating or enablingfactors in partner communication, and methods of communication.FindingsOf the fifteen interviewed, seven were men and eight women. All but four (three women andone man) were unmarried. All women stated they were in a relationship with one primarypartner, and all but two of the men were in similar relationships. The other two men statedthat they had a number of different partners. Ages of the women ranged from 19 to 27, and ofthe men from 23 to 30.There are several important preliminary results from these interviews, which are outlinedbelow.There was clear gender variation in patterns of sexual networking: men were much morelikely to discuss multiple partners in the recent past (i.e. past three months);women weremuch more likely to discuss one partner only.Both men and women were initially prepared to notify only one partner (usually a steadypartner) of their illness. Men were more willing to notify several partners after counsellingabout reasons for doing this.Both men and women drew clear distinctions between regular partners and ‘casual’partners. A regular partner was often described as a ‘girlfriend’ or ‘someone I live with’; acasual partner was often described as ‘someone I just met’ or ‘I don’t see very often’, or‘someone who lives away’.The majority of respondents placed great importance on the role of trust in promotingcommunication between partners; many respondents said they could tell a regular partnerabout their illness because they ‘trust’ them. Trust also implied a responsibility to ‘take careof’ that person (i.e. by referring the partner for STD treatment).Personal communication was stressed by both male and female respondents as the mostappropriate way of letting their partner know about their STD. Men and women made clearthat communication about an STD could be difficult and embarrassing. Most respondents feltthat the partner notification process,particularly with a card from the health service, facilitatedcommunication about their illness. This type of communication was felt to be easier withregular partners who are ‘well known’ and ‘trusted’.Some men and women expressed fear or anxiety about telling partners of their STD. Malerespondents were generally embarrassed but said they felt their partners would understand;women respondents worried that they would be viewed as ‘having done something wrong’ orbe seen as ‘unfaithful’ or ‘unclean’.Exploring partner communication and patterns of sexual networkingSupplement 3 to Health Transition Review Volume 7, 1997105DiscussionResponses from both men and women indicate the prevalence of multiple partnerships in thissetting. In particular, men’s sexual networks appear to be quite extensive, and these patternsof sexual partnership appear to be at least tacitly accepted by both men and women. Mostmale respondents were unmarried, and considerable fluctuation was apparent in their ‘regular’partnerships.When asked about multiple partners, many women laughed and dismissed the subject,stating that ‘it is men who do such things, not women’. Since most female respondents weremarried, cultural constraints to discussing additional partners are likely to have played astrong role in these statements. In fact, most married women appear to have very fewadditional partners. For those women who do not fit into this accepted pattern, socialstigmatization can be severe. This highlights the need to understand better how women pursuemultiple partnerships, particularly within marriage, and how these patterns change in caseswhere the husband lives away from home.Within the context of multi-partnered sex, all of the women and almost all of the men hadone regular partner to whom they felt a strong attachment. The distinction between ‘regular’and ‘casual’ partners was drawn particularly clearly by men, most of whom felt aresponsibility toward their primary, steady partner. This point is highlighted by the fact thatno respondents stated they had more than one ‘regular’ partner at a time. The use of the term‘casual’ partner by men could mean anything from someone they see regularly outside theirprimary relationship to a one-time sexual encounter. Some men referred to a number of‘casual’ partners whom they saw regularly outside their primary relationship. More workneeds to be done to understand these relationships and men’s perceptions of them.Notably, among most of the men interviewed, the idea of ‘responsibility’ toward a regularpartner does not extend to limiting sexual relations outside that partnership. This is true eventhough a number of men identified the probable source of their STD as a recent ‘casual’partner.For most women, the importance of a ‘regular’ partner was stressed, even when a womanhad several regular partnerships during the course of the last year. No women discussedhaving more than one partner currently. These findings strongly suggest the continuingimportance of traditional social norms that prevent women from acknowledging sexualrelations outside their primary partnership, and suggest that being in a steady partnershiphelps to conform to these norms.At the same time, sexual networks appear to be highly unstable for both unmarriedwomen and for men, both married and unmarried. The predominant pattern of sexualnetworking for women seems to be serial monogamy. Marriage appears to introduce a periodof extended monogamy with one partner for most women. Thus, the number of lifetimepartners and their turnover rate is probably quite small compared to men. However, it is likelythat the patterns vary during different periods in life. More work needs to be done tounderstand women’s sexual activity throughout the life cycle, particularly patterns ofpartnership among different age groups. In contrast, it is the norm for men to pursue multiplepartnerships. As a result, even women in long-term, monogamous partnerships face aheightened risk for STDs.Although most women did not discuss their own sexual relationships outside theirprimary partnerships, several did discuss quite freely the idea that their primary partners musthave other sexual relationships and that this was the probable source of their STD. Mostidentified their primary partner as the probable source of their STD.The prevailing theme of trust that emerged as a determinant of partner communicationmust be considered carefully. It is interesting that many women expressed trust in theirregular partners, even though the presence of an STD suggested to many of them that theirA. Harrison, M. Lurie and N. WilkinsonSupplement 3 to Health Transition Review Volume 7, 1997106partners were involved in other sexual relationships. On the one hand, established trust with aregular partner appeared to ease the path toward discussion of STDs. On the other hand, theperception that trust was an important ingredient in partner communication also seemed toindicate, particularly for men, that they would not be motivated to contact a casual partner,with whom they did not have such a relationship.Although about half of the women said they would find no problem in discussing theSTD with their partners, it is alarming that others did express anxiety or fear about doing so,and  feared that they would be seen as ‘unclean’ or ‘unfaithful’. Other research in similarsettings has shown that women may face the risk of violence when informing a partner oftheir HIV status (Temmerman et al. 1995;Van der Straten et al. 1995), and that the spectre ofviolence permeates many sexual relationships (Varga and Makubalo 1996).Notably, only two respondents, both women, raised the issue of HIV/AIDS during theinterview. This may indicate a lack of awareness about the relationship between HIV andother STDs, although this issue was raised explicitly in each of the counselling sessions thattook place before the interviews.On the other hand, the women interviewed here were not dealing explicitly with the issueof HIV/AIDS. Although STDs are seen as shameful and embarrassing, they are commondiseases that have been known for some time. Zulu medical ethnographies documentcategories of disease that are analogous to STDs, such as umhlombe (a discharge), and soresthat can be caused by jealousy or stepping over something placed on the ground  (Ngubane1977). Whereas STDs are well known and understood within local explanatory models,HIV/AIDS is not. Although basic awareness is increasing, the epidemic remains at a levelwhere relatively few people have felt its impact. This is enhanced by heavy socialstigmatization which prevents open discussion about HIV/AIDS and limits educationalopportunities.These findings suggest a need to explore further the balance of power within sexualrelationships, and to understand better how women negotiate and discuss issues such as asexually transmitted disease. Expressions of fear and anxiety must be taken seriously whenrecommending strategies such as partner notification that confer responsibility upon a sexualpartner without fully considering the relationship in which that partner exists. Women’sapparent acceptance of multiple partnerships among men must be more carefully examinedand understood. These issues further emphasize the need to contextualize strategies topromote sexual health within a better understanding of social processes and norms.All of these findings have important implications for reducing the spread of sexuallytransmitted diseases. It is clear even from this limited research that notification of partnersabout an STD has far more to do with partner relations and the perceived importance of therelationship than with notions of disease transmission. This is an important consideration,particularly as these interviews were conducted after a counselling session in which basicfacts about STDs and the importance of partner notification were stressed. Although somerespondents did indicate that they would notify the partner from whom they thought they gotthe STD, the assumption was made frequently, particularly by men, that this must have been arecent ‘casual’ partner.These findings have raised some important issues about patterns of partnercommunication. Understanding the processes of sexual networking is also important forsuccessful prevention strategies, and these need to be further explored. It is important tounderstand that partner networks are fluid and changing, not static, and that communicationbetween partners in a network depends on power dynamics within relationships andperceptions of different types of partners. In a social setting in which multi-partnered sexualactivity is widely accepted, particularly for men, the success of partner notification strategiesdepends on incorporating these realities.Exploring partner communication and patterns of sexual networkingSupplement 3 to Health Transition Review Volume 7, 1997107ReferencesFaxelid, E., J. Ndulo, B.M. Ahlberg and I. Krantz. 1994. Behaviour, knowledge and reactionsconcerning sexually transmitted diseases: implications for partner notification in Lusaka. EastAfrican Medical Journal 71,2:118-121.Moses S., E. Muia, J. Bradley, et al. 1994. Sexual behavior in Kenya: implications for sexuallytransmitted disease transmission and control. Social Science and Medicine 39,12:1649-1656.Ngubane, H. 1977. Body and Mind in Zulu Medicine: An Ethnography of Health and Disease inNyuswa-Zulu Thought and Practice. London: Academic Press.Orubuloye, I., J.C. Caldwell and P. Caldwell. 1993. African women’s control over their sexuality in anera of AIDS. Social Science and Medicine 37,7:859-872.Standing, H. 1992. AIDS: conceptual and methodological issues in researching sexual behaviour in Sub-Saharan Africa. Social Science and Medicine 34,5:475-483.Steen, R., C. Soliman, S. Bucyana and G. Dallabetta. 1996. Partner referral as a component of integratedsexually transmitted disease services in two Rwandan towns. Genitourinary Medicine 72:56-59.Sturm, A.W., D Wilkinson, N.N. Ndovela, A. Harrison, M. Lurie and C. Connolly. forthcoming.Asymptomatic and unrecognised genital tract infections among young women in rural SouthAfrica. Genitourinary Medicine.Temmerman, M., J. Ndinya-Achola, J. Ambani and P. Piot. 1995. The right not to know HIV-testresults. Lancet 345:969-970.Van der Straten, A., R. King, O. Grinstead, A. Serufilira and S. Allen. 1995. Couple communication,sexual coercion and HIV risk reduction in Kigali, Rwanda. AIDS 9:935-944.Varga, C. and L. Makubalo. 1996. Sexual non-negotiation. Agenda 28:31-38.Winfield, J. and A. Latif. 1985. Tracing contacts of persons with sexually transmitted diseases in adeveloping country. Sexually Transmitted Diseases  12,1:5-7.

Exploring partner communication and patterns of sexual networking: qualitative research to improve management of sexually transmitted diseases

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