Young women and girls' vulnerability is both physiological and social. Physiological factors account for the more efficient transmission of HIV from an infected man to a woman than from an infected woman to a man. Additionally, young women and girls are particularly susceptible to HIV and other STIs because their reproductive tracts are still developing and not yet fully able to resist infection. However, the special vulnerability of girls and young women stems from the socio-cultural norms around gender, age, femininity and masculinity, which restrict young women and girls' access to knowledge, skills, and opportunities to protect themselves from the affects of HIV and AIDS.

Gender and age: a double disadvantage

Gender – the cultural expectations, traditions, and norms about appropriate female and male attributes and behaviour – greatly influences the extent to which an individual is vulnerable to HIV/AIDS. While gender is a culture-specific construct with clear variation across cultures, there are also consistent differences between women and men's roles, access to productive resources, and decision-making authority. In many societies, men are expected to be responsible for the productive activities outside the home, while women are expected to be responsible for the reproductive and productive activities within the home. In general, women have less access to and control of productive resources than men, creating an unequal balance of power that favours men. Gender gaps between women and men in literacy, school enrolment, labour force participation, land ownership, and access to credit testify to this imbalance in power.

Age, like gender, is a hierarchically ordered status that assigns power unequally. In general, youth have significantly less power than older adults. Again, similar to the inequalities associated with gender, this power imbalance is demonstrated in youth's lack of access to economic opportunities, decision-making, and other resources compared to older adults.

Young women and girls occupy the space where the lowest ends of these two hierarchies converge and are thus at a double disadvantage, leaving them with less power than men, boys, and older women. Young women and girls' lack of power, associated with both their age and gender, is critical to HIV/AIDS because it directly translates into a lack of power in sexual interactions. In general, young women and girls have the least amount of control over when, where, with whom, and how they have sex. Additionally, when they are able to exercise choice and control they often do not have the knowledge to act safely. This vulnerability is intricately tied to social norms about femininity and masculinity which maintain the imbalance of power unfavourable towards young women and girls.

Norms of femininity

Norms about female behaviour greatly influence the access of young women to information and services and the possibilities they have to protect themselves from abusive and risky relationships.

Virginity and the culture of silence – For many cultures around the world, virginity is the dominant framework within which young unmarried women and girls are encouraged to understand their bodies, sexual interests, and experiences. The ideal of virginity is often located in a larger culture of silence surrounding sex, which dictates that ‘good' girls, whether married or not, must be ignorant about sex and passive in sexual interactions. This framework prevents young women and girls from receiving information, as well as asking for it. Many young women and girls do not request information about sex out of fear that they will be thought to be sexually active, a status that can result in social isolation and punishment from peers and older adults.

Ignorance about sex, reproductive anatomy, and HIV prevention increases young women and girls' vulnerability to HIV infection by making it difficult or even impossible for them to reduce their HIV risk. Other studies have shown that lack of knowledge makes it difficult for women to be proactive in negotiating safer sex with their husbands or other partners.³ Further, the virginity ideal can pressure girls into risky behaviour both knowingly and unknowingly. In cultures where virginity is highly valued, some young women practice high-risk sexual behaviours, such as anal sex, in order to preserve their virginity.⁴

Marriage and motherhood – Along with the ideals of virginity and purity, million of girls in the developing world are married early (before the age of 18), and as a result are denied schooling, good health, economic opportunities, and friendship with peers. These denials deprive young women of their basic rights and put them in risky situations. Young women generally enter into marriage with partners who are much older and more sexually experienced. In these unions, women have little negotiating power in sexual behaviour and practices, putting them at greater risk of contracting reproductive and sexually transmitted infections (STIs), including HIV.⁵ Recent data shows that married adolescent girls tend to have higher rates of HIV infection than their sexually active unmarried peers.⁶

For young married women or those in other unions, motherhood is another powerful feminine ideal that puts them at risk. Bearing children is critical and in many cases the only way for young married women to secure their social identity, marriage, and status in the household. Thus, the use of barrier methods or non-penetrative sex as safer sex options presents an extremely difficult choice for women because they also prevent pregnancy. Additionally, once young women do become mothers, programmes that seek to prevent mother-to-child transmission by encouraging women not to breastfeed can stigmatize women. Breastfeeding is often an integral part of the ideal of motherhood and in many places women who do not breastfeed are treated as bad mothers or promiscuous people.

Women as care givers – Related to the motherhood ideal is the common norm that women and girls are responsible for the family's well-being. This norm places the greater burden of the effects of HIV/AIDS on young women and girls. For example, girls are much more likely than boys to be pulled out of school to help with the care of an HIV-infected household member or to fill the gap in food production or income. From high-prevalence settings it is well-established that the combined physical and emotional burdens of caring for sick family members and ensuring food security under harsh economic conditions, often takes a toll on women's own health and well-being.

Leaving school early to marry or care for the household or ailing family members also prevents young women and girls from obtaining the education and skills necessary to take advantage of economic opportunities. This economic vulnerability, in turn, encourages young women to engage in unprotected sex, especially with older men, in exchange for school fees, gifts, money, or favours.⁷ The lack of economic options also makes it less likely that young women will succeed in negotiating protection or be willing or able to leave a relationship that they perceive to be risky.⁴

Norms of masculinity

Norms surrounding masculinity contribute to the vulnerability of young women and girls, as well as the vulnerability of young men and boys.

Proving their manhood – In general, men are accorded sexual ‘privileges' that encourage them to experiment with sex in unsafe ways – by having multiple partners, not using condoms, and engaging in sex with sex workers – in order to prove their ‘manhood'. For example, a study of Xhosa township youth in South Africa found that ‘successful' masculinity hinged on a young man's number of partners, the sexual desirability of his main partner to other men, and his ability to control girlfriends.⁸

Dominance over women – Norms of masculinity that emphasize domination over women through violence and coercion also contribute to young women and girls' risk of infection. Young women and girls are exposed to sexual coercion in a variety of places from husbands, other family members, peers, friends, and strangers. Disturbingly, young women and girls are also at risk of sexual coercion and violence at school. Ongoing studies in sub-Saharan Africa have found that sexual abuse of girls in schools by male teachers and students is common and accepted.⁹ Domestic violence also presents a significant barrier for young women who are married or in partnerships to practice safer sex and seek testing and treatment. Often, women do not ask their partners or husbands to wear condoms for fear of a violent reaction.¹⁰ Similarly, many women do not seek treatment or testing and choose not to disclose their test results to partners and husbands for fear of violence.

Sexual coercion and violence put young women and girls at risk of HIV infection both directly and indirectly. Most obviously, violent sexual acts, such as rape, are likely to result in vaginal tearing or lacerations, thus dramatically increasing the risk of contracting an STI or HIV. Further, women who have been raped or abused when they were young are more likely to engage in high-risk behaviour, including having multiple partners and using intravenous drugs, when they are older.^11-12

Key strategies for reducing vulnerability

In order to empower young people to reduce their vulnerability, programmes need to make use of some well-described key strategies (see also the Box). Some of these strategies have been explored by programmes described in this special issue of Sexual Health Exchange. These strategies are:

1. Provide comprehensive education on HIV/AIDS prevention, treatment, care and support within a context of sexuality, relationships, and broader reproductive health concerns

2. Create a safe space to explore, understand and internalize information

3. Enhance the provision of services that cater for the needs of young people, especially girls

4. Foster a social environment that supports young women and girls' access to information and services

5. Involve young women and girls, especially women infected or affected by HIV/AIDS, in programme design and implementation.

There is no single way to successfully address young women and girls' unique vulnerability to HIV/AIDS. In the short term, a variety of programmes that provide youth-friendly services, information, and skills in gender-sensitive ways are our best hope. Such programmes must continue to address young women and girls' vulnerability by continually adapting to and meeting their special needs within the current context.

In order to have a lasting impact, however, programmes to change women's knowledge, information, and services are not sufficient. We cannot provide information and services to young women and girls alone and expect them to protect themselves in difficult environments where they are at a double disadvantage because of their age and gender. In the face of this epidemic, programmes have to work with communities, especially young women and key stakeholders, to bring about a context that supports the rights of young women and girls – to be educated, to marry later, to be safe from harm in school and at home, to be able to access health services, and to be able to access resources to support themselves and their families. In order to address young women and girls' vulnerability in the long term we must change the environment that puts them at risk and prevents them from protecting themselves.

References

1. UNICEF/UNAIDS/WHO. 2002. Young People and HIV/AIDS: Opportunity in Crisis. NY: UNICEF; Kiragu, K. 2001.

2. Youth and HIV/AIDS: Can we avoid catastrophe? Population Reports, Series L, No. 12. Baltimore: The Johns Hopkins University Bloomberg School of Public Health, Population Information Program.

3. Carovano, K. 1991. "More than Mothers and Whores: Redefining the AIDS prevention needs of women." International Journal of Health Services 21(1):131-142.

4. Weiss, E, Whelan D, and G R Gupta. 1996. Vulnerability and Opportunity: Adolescents and HIV/AIDS in the Developing World. Washington DC: International Center for Research on Women.

5. Mathur, S, Greene, M and A Malhotra 2003. Too Young To Wed: The Lives, Rights, and Health of Young Married Women. Washington DC: International Center for Research on Women.

6. Bruce, J and S Clark. 2004. The implications of early marriage for HIV/AIDS policy, brief based on background paper prepared for the WHO/UNFPA/Population Council Technical Consultation on married Adolescents. New York: Population Council

7. Luke, N. and K Kurz. 2001. Cross-generational and Transactional sexual Relations in Sub-Saharan Africa: A Review of the Evidence on Prevalence and Implications for Negotiation of Safe Sexual Practices for Adolescent Girls. Washington, DC, International Center for Research on Women: 63.

8. Wood K; Jewkes R. 2001. "Dangerous love? Challenging male machismo." Insights: Development Research. Aug(1).

9. Leach, F. 2001. "Conspiracy of silence? Stamping out abuse in African schools." Insights Gender Violence Special Issue: July.

10. Maman, S., J. Campbell, Sweat, MD, and AC Gielen. 2000. "The Intersections of HIV and Violence: Directions for Future Research and Interventions." Social Science and Medicine 50(4): 459-478.

11. Heise L; Garcia-Moreno C. 2002.Violence by intimate partners. In: World report on violence and health, edited by Etienne G. Krug, Linda L. Dahlberg, James A. Mercy, Anthony B. Zwi and Rafael Lozano. Geneva, Switzerland, World Health Organization [WHO], :87-121. 121 p.

12. Heise L; Ellsberg M. 2001.Violence against women: impact on sexual and reproductive health. In: Reproductive health, gender and human rights: a dialogue, edited by Elaine Murphy and Karin Ringheim. Washington, D.C., Program for Appropriate Technology in Health.