Multi-Country Study on Gender, Multi-Country Study on Gender, Sexuality and Vaginal PracticesSexuality and Vaginal Practices

IAS Satellite SymposiumIAS Satellite Symposium

20 July 200920 July 2009

Adriane Martin Hilber (ISPM - Switzerland)Adriane Martin Hilber (ISPM - Switzerland)

Terence Hull (ANU - Australia)Terence Hull (ANU - Australia)

Matthew Chersich (U.Gent - Belgium & RHRU- Matthew Chersich (U.Gent - Belgium & RHRU- South Africa)South Africa)

for the GSVP Study Groupfor the GSVP Study Group

Classification of Vaginal PracticesClassification of Vaginal Practices 1.1. Washing of external genitaliaWashing of external genitalia

2.2. Intravaginal cleansing Intravaginal cleansing (wiping/douching)(wiping/douching)

3.3. Application of (substances or Application of (substances or steam) to external genitaliasteam) to external genitalia

4.4. Intravaginal insertionIntravaginal insertion

5.5. Oral ingestionOral ingestion

6.6. Anatomical modification of Anatomical modification of vagina (surgery, traditional vagina (surgery, traditional scarification or labial scarification or labial elongation)elongation)

.. a variety of .. a variety of behaviours behaviours undertaken for undertaken for diverse motives, diverse motives, with the common with the common element that they element that they involve some involve some modification of the modification of the labia, clitoris or labia, clitoris or vagina.vagina.

Study objectivesStudy objectives

1.1. What is the What is the prevalence and frequency prevalence and frequency of vaginal practices of vaginal practices within each study population? within each study population?

2.2. What are the What are the reasonsreasons women undertake these vaginal women undertake these vaginal practices? practices?

3.3. What impact do these practices have on women’s and men’s What impact do these practices have on women’s and men’s self-perceived sexual satisfaction and experience? self-perceived sexual satisfaction and experience?

4.4. What impact do these practices have on women’s and men’s What impact do these practices have on women’s and men’s self-perceived reproductive health? self-perceived reproductive health?

5.5. To what extent are the practices promoted by women’s To what extent are the practices promoted by women’s sexual partners, or by other members of the community, sexual partners, or by other members of the community, including traditional and modern health service providers?including traditional and modern health service providers?

Project OverviewProject Overview

• Phase 1 (2004-06) Phase 1 (2004-06) Qualitative StudyQualitative Study to improve to improve understanding of the nature, motivations and understanding of the nature, motivations and circumstances of these complex practicescircumstances of these complex practices

• Phase 2 (2006-2007) Phase 2 (2006-2007) Household SurveyHousehold Survey to to determine the population-level prevalence of determine the population-level prevalence of practices, and the intended and adverse effects of practices, and the intended and adverse effects of practicespractices

• Study in Study in Mozambique (Tete), South Africa (Kwa-Mozambique (Tete), South Africa (Kwa-Zulu, Natal), Indonesia (Yogyakarta), & Thailand Zulu, Natal), Indonesia (Yogyakarta), & Thailand (Chonburi)(Chonburi); Kenya in 2009-2010; Kenya in 2009-2010

GSVP Survey Methods (1)GSVP Survey Methods (1)

• Phase 1 qualitative: Key Informant & In Depth Interviews; Phase 1 qualitative: Key Informant & In Depth Interviews; FGDs – results informed the questionnaireFGDs – results informed the questionnaire

• Phase 2 Household Survey: Phase 2 Household Survey:

– 850 randomly selected women 18-60 years 850 randomly selected women 18-60 years

– multi-stage cluster sample designmulti-stage cluster sample design

– clusters were census enumeration areas (+/-100 HH) clusters were census enumeration areas (+/-100 HH)

– HH selection per cluster: 20/Asia, 30/Africa HH selection per cluster: 20/Asia, 30/Africa

– generic structured questionnaire; with local adaptations and generic structured questionnaire; with local adaptations and additional categories additional categories

GSVP Survey Methods (2)GSVP Survey Methods (2)

– Descriptive analysis of practices characteristics within a Descriptive analysis of practices characteristics within a standard frameworkstandard framework

– Multivariate analysis to identify population groups with Multivariate analysis to identify population groups with high levels of practices high levels of practices

– Study estimates were weighted for differential probabilities Study estimates were weighted for differential probabilities of inclusion and response.of inclusion and response.

• WHO and local ethical approvalsWHO and local ethical approvals

Qualitative findingsQualitative findings• Vaginal Practices are motivated by:Vaginal Practices are motivated by:

– Desire for improvedDesire for improved sexual relationssexual relations to tighten, warm, close or dry the vagina (e.g.Dry to tighten, warm, close or dry the vagina (e.g.Dry Sex)Sex)

– hygienehygiene (e.g. douching, washing, cleansing, steaming, application) and are done in (e.g. douching, washing, cleansing, steaming, application) and are done in association with specific life events (e.g. menses, marriage, child birth, menopause)association with specific life events (e.g. menses, marriage, child birth, menopause)

– healthhealth (e.g. to eliminate discharge, self treat a suscepted STI, induce an abortion) (e.g. to eliminate discharge, self treat a suscepted STI, induce an abortion)

• Women use a variety of products (natural and commercial preparations) in their vaginal Women use a variety of products (natural and commercial preparations) in their vaginal practicespractices

• Frequency of practices varies depending on motivation, product used, life event, desired Frequency of practices varies depending on motivation, product used, life event, desired effecteffect

External External washingwashing

External External applicationapplication

Anatomical Anatomical modificationmodification

Intravaginal Intravaginal cleansingcleansing

Intravaginal Intravaginal insertioninsertion

Oral Oral IngestonIngeston

ProductsProducts

PrevalencePrevalence

Timing Timing

MotivationMotivation

Intended effects

Adverse effects

Framework for measuring vaginal practices

PrevalencePrevalence

Prevalence of practices-African sitesPrevalence of practices-African sites

Mozambique n=1025

South Africa n= 867

Adverse events MozambiqueAdverse events Mozambique

Adverse events South AfricaAdverse events South Africa

ConclusionsConclusions

General PatternsGeneral Patterns• HygieneHygiene

– CleanlinessCleanliness– OdorOdor

• HealthHealth– Disease prevention, control or treatmentDisease prevention, control or treatment

• SexualitySexuality– Competition for sexual partners among young womenCompetition for sexual partners among young women– Competition against young women among married Competition against young women among married

middle aged womenmiddle aged women– ““Performance enhancement”Performance enhancement”– Self-fulfillment – less clear Self-fulfillment – less clear

Tightening or drying?Tightening or drying?

• Friction favored by both men and womenFriction favored by both men and women• This could be achieved through warming, tightening, This could be achieved through warming, tightening,

closing (or elongated labia in Mozambique)closing (or elongated labia in Mozambique)• ““Dryness” per se was only intended where there was Dryness” per se was only intended where there was

obvious wetness to such an extent that the partner obvious wetness to such an extent that the partner complained of infidelity or discomfortcomplained of infidelity or discomfort

Health ImplicationsHealth Implications• Life-time experience of Life-time experience of side effects commonside effects common, and asymptomatic , and asymptomatic

genital lesions or inflammation are likely even more common. genital lesions or inflammation are likely even more common. Genital bleeding and sores more frequent in Asian sites though the Genital bleeding and sores more frequent in Asian sites though the higher prevalence of practices in Africa makes side effects here higher prevalence of practices in Africa makes side effects here more concerningmore concerning

• Women are less likely to use a condom or other barrier methods Women are less likely to use a condom or other barrier methods for contraception or for dual protection as most practices imply for contraception or for dual protection as most practices imply ‘skin to skin’‘skin to skin’ contact contact

• There was significant use of a myriad of practices to address other There was significant use of a myriad of practices to address other SRH concerns including induced SRH concerns including induced abortionabortion and and self treatment of self treatment of vaginal dischargevaginal discharge and other symptoms of STIs and other symptoms of STIs

Acknowledgements of partners Acknowledgements of partners and fundersand funders

• Partnering organisations – ANU (Australia), CRDS Partnering organisations – ANU (Australia), CRDS (Mozambique), ICRH (Kenya & Mozambique, Beligum), ISPM (Mozambique), ICRH (Kenya & Mozambique, Beligum), ISPM (Switzerland), Mahidol University (Thailand), RHRU (South (Switzerland), Mahidol University (Thailand), RHRU (South Africa), Women‘s Health Foundation (Indonesia), WHOAfrica), Women‘s Health Foundation (Indonesia), WHO

• Funders – AUSAid,Australian National Research Council, Funders – AUSAid,Australian National Research Council, Flemish Government, Ford Foundation, International Partnership Flemish Government, Ford Foundation, International Partnership for Microbicides, UNAIDS, USAID, WHOfor Microbicides, UNAIDS, USAID, WHO

AsiaAsiaIndonesia TeamIndonesia Team• Ninuk Widyantoro, Women’s Health FoundationNinuk Widyantoro, Women’s Health Foundation• Herna Lestari , Mintra Inti FoundationHerna Lestari , Mintra Inti Foundation• Laily Hanifah, Mintra Inti FoundationLaily Hanifah, Mintra Inti Foundation• Besral Madras, Mintra Inti FoundationBesral Madras, Mintra Inti Foundation• Iwu Utomo, Australia National UniversityIwu Utomo, Australia National University

Thai TeamThai Team• Aree Prommho, Institute for Population and Social Aree Prommho, Institute for Population and Social

Research, Mahidol University Research, Mahidol University • Kullawee Siriratmongkon, Mahidol University Kullawee Siriratmongkon, Mahidol University • Susinee Worasrisothon, Mahidol University Susinee Worasrisothon, Mahidol University • Chintana Wacharasin, Faculty of Nursing, Burapha Chintana Wacharasin, Faculty of Nursing, Burapha

University University • Monruedee Lapimon, Thai Women AIDS Task ForceMonruedee Lapimon, Thai Women AIDS Task Force

AfricaAfricaMozambique Team Mozambique Team • Brigitte Bagnol, ICRH Mozambique (consultant)Brigitte Bagnol, ICRH Mozambique (consultant)• Esmeralda Mariano, Eduardo Mondlane University Esmeralda Mariano, Eduardo Mondlane University • Francisco Mbofana, CRDS/MISAUFrancisco Mbofana, CRDS/MISAU• Isabel FranIsabel Franççois, ICRH Mozambique (consultant)ois, ICRH Mozambique (consultant)• Elise Kenter, ICRH Mozambique (consultant)Elise Kenter, ICRH Mozambique (consultant)• Hipolito Nzwalo, Ministry of Health, Mozambique (MISAU)Hipolito Nzwalo, Ministry of Health, Mozambique (MISAU)

South Africa Team South Africa Team • Jenni Smit, RHRUJenni Smit, RHRU• Busi Kunene, RHRUBusi Kunene, RHRU• Ntsiki Manzini, RHRUNtsiki Manzini, RHRU• Matthew Chersich, RHRU/ICRHMatthew Chersich, RHRU/ICRH• Mags Beksinska, RHRUMags Beksinska, RHRU