Alcohol use as part of the construction of maleness
Across project sites studied in the WHO report drinking was manifested as a lifestyle and indispensable part of social life, integral in partnership development and functional in sexual encounters. In all the countries – except in India – alcohol consumption was believed to signify maleness. In South Africa, for example, “being able to hold one’s drink and drink heavily were regarded as sign of masculinity”.
The report concludes that being under the influence of alcohol was culturally accepted as an excuse for irresponsible behaviour, including risky sex, in Kenya and South Africa, in Mexico, as well as in Belarus, Romania and the Russian Federation. In Romania, alcohol consumption was not only culturally accepted as an excuse for irresponsible behaviour but also as an excuse that specifically applied to men, implying that alcohol use-related irresponsible behaviour was culturally accepted as an assertion/manifestation of maleness.
Alcohol was consumed to attract sexual partners and initiate sexual encounters, says the report. For example, in Zambia “buying alcohol for women showed that a man had money”. In Belarus in particular “alcohol use was conventional and an essential part of sexual relations”; and “at discos alcohol was much more consumed by those who showed up single and searched for a partner than those who came with a partner”.
From another study in Sri Lanka, though not related to HIV/AIDS, the masculinity issue is still pointed out. Sex and suppression of women, including domestic violence is a hot topic in the drinking settings and the men even boasted about hitting women as a way of expressing masculine norms and identity.
Alcohol as a facilitator for sexual encounters and intercourse
Beliefs that alcohol facilitates or enhances sexual intercourse contribute towards consumption before or during sexual intercourse, according to the WHO study. Alcohol is commonly used as a disinhibitor, a sex facilitator, a symbol of masculinity, and a means of relaxation, recreation, socializing and improving communication skills (e.g. in Mexico and Romania). Alcoholic beverages are also used as a facilitator in approaching the opposite sex.
“Masculinity” is often linked to the ability to have multiple partners, imbibe alcohol and engage in promiscuous behaviour. Among women, alcohol use increases involvement in risky sexual encounters and sexual victimization, exposing them to the risk of unwanted pregnancies and STIs (e.g. in the Russian Federation and South Africa).
In Kenya it was observed that “alcohol use was believed to reduce fears connected to sex and encouraged risky sex, and to provide extra power for sex”; and in South Africa some research participants noted that “alcohol use and sex were a match made in heaven”. In Mexico “young people and homosexual men used alcohol to build courage to approach a possible sexual contact”. The research results also indicated that in India “alcohol’s positive effect on arousal and pleasure was particularly reported by high-risk groups”. In Belarus “alcohol use was perceived as very important in sexual activity”, with some persons noting that alcohol use during sexual intercourse made “them become more attractive”. It was also found in Belarus that alcohol use was the third most frequent reason for girls to have sex the first time. In Romania it was noted that, as a rule, “alcohol was taken as a socializer and a facilitator of sex”. In the Russian Federation “there was a common misconception that a person without alcohol was incapable of engaging in sex”.
Alcohol-serving places as contact places for sexual encounters
The WHO study draws attention to the role of situations and venues, just as much as target groups and vulnerable groups, in the understanding of the links between alcohol and HIV/AIDS. This approach, moreover, corresponds with a trend in general HIV prevention to have a stronger focus on venues of risk.
The WHO study identified drinking places like bars, restaurants etc as venues were the combination of alcohol and sexual encounters lead to an increased risk of HIV transmission. In addition to this general observation, the report points at what they call “tricky issues”. On the examples under this paragraph is from Mexico: “In Mexico some members of NGOs with a health promotion mission were owners of venues that animated/encouraged high-risk sex, e.g. dark rooms (for anonymous sex). Furthermore, drinking venues posed particular problems in Mexico. There were places and particularly drinking venues and strategies that induced customers to engage in extremely risky behaviour, e.g. certain bars in Mexico City where one could get to the rest room only by passing the “dark room” (and there were only men’s rest rooms). (In South Africa the drinking venues in certain sites had similar problems, such as shared toilets, poor lighting, sexual harassment of women by owners and sellers, and very low levels of disapproval of risky sexual behaviours in the venues.) In Mexican beer halls, food was sometimes offered for free if a customer drank a certain number of beers. Moreover, drinking venues also hosted contests to see who was able to drink the most. The contests were organized by the owners and the reward was alcohol. Men and women participated. In some bars visitors were “forced” to drink by waiters walking among them and offering them tequila (for the competition).
Denial and neglect of risk as a way of coping with life
The results of the WHO study link alcohol consumption also to prostitution, where drinking becomes a way of living with risks and coping with life. Alcohol consumption occurred in the study as an outcome of (stressful) sexual encounters in some of the project countries. For example, in Kenya it was reported that some commercial sex workers “drank to cope with dirty clients”, and in India female commercial sex workers reported that alcohol was used “to cope with” commercial sex.
Alcohol in special risk groups
The WHO report points to the fact that certain groups are in particular vulnerable to the combination of alcohol and risky sex; female commercial sex workers (FCSW), truck drivers and youth.
“Alcohol use and sexual risk behaviour go hand in hand in commercial sex encounters. FCSWs use alcohol to cope with the pressures of their work, e.g. a large number of sexual encounters. Many a time they and their clients use alcohol together. Condom use is more evident among paying sex partners than non-paying sex partners of sex workers. Brothel-based workers are able to negotiate condom use better than non-brothel-based workers in India. Most studies suggest that there is greater consistency of condom use in commercial sex than in private encounters, but that levels of alcohol use do not necessarily alter levels of condom use. However, clients’ alcohol use has emerged as an important determinant of condom use in some studies. Other studies have found no differences in condom use between FCSWs who use alcohol and those who do not.
Drinking alcohol and visiting commercial sex workers are evident among long-distance drivers all over the world. Transport workers and migrant populations who frequently visit FCSWs, spread STIs and HIV infection from one place to the other and from high-risk groups to the general population. IDUs (injecting drug users) who are sexually active contribute to the spread of HIV infection in Belarus, the Russian Federation, Romania and India.
Alcohol use, especially among young adolescents, is associated with casual sex encounters, traffic accidents, violence, crime and social problems (e.g. in Belarus, South Africa, Mexico). Early sexual experience, a high level of risk taking and alcohol use increase the risk of contracting STIs and HIV among adolescents.
”Groups vulnerable to alcohol use, sexual risk behaviour and HIV Alcohol use is associated with certain types of sexual activity, concludes the WHO report: “Crime often plays a role in unprotected casual sex, group sex and anal sex when participants in these activities are under the influence of alcohol. Alcohol use has also been linked to early sexual experiences (e.g. Belarus, the Russian Federation, Kenya and South Africa). Alcohol use and sexual risk behaviours are particularly prevalent in settings such as nightclubs, bars, dark houses, highway eating joints and motels, and brothels.
Furthermore, alcohol is commonly used as a disinhibitor, a sex facilitator, a symbol of masculinity, and a means of relaxation, recreation, socializing and improving communication skills (e.g. in Mexico and Romania). Alcoholic beverages are also used as a facilitator in approaching the opposite sex. “Masculinity” is often linked to the ability to have multiple partners, imbibe alcohol and engage in promiscuous behaviour. Among women, alcohol use increases involvement in risky sexual encounters and sexual victimization, exposing them to the risk of unwanted pregnancies and STIs (e.g. in the Russian Federation and South Africa). It has also been shown that alcohol use and sexual risk behaviours increase during certain festivities and celebrations across countries (e.g. in South Africa, Kenya and Romania).
Alcohol use and promiscuity are customary during funerals among certain population groups in Kenya. In contrast, certain religions and religious sects prohibit the use of alcohol and indulgence in risky sexual practices. Dry sex (a preference among certain rural tribes in Zambia and South Africa), sexual cleansing and levirate marriage (Zambia) increase the risk of STIs in Africa. The media (electronic and print) play an important role in shaping and influencing sexual behaviour and alcohol use patterns. Certain advertisements, pornographic movies, thrillers and romantic programmes glamorize and promote engagement in these activities.
High-risk sexual behaviours and alcohol; case Botswana
A recent population based study on alcohol and high-risk sexual behaviours in Botswana concluded that alcohol use is associated with multiple risks of HIV transmission both among men and women. As many as 31 % of men and 17 % of women met the criteria for heavy drinking. Such alcohol use patterns was associated with risky sex among both men and women, including unprotected sex, multiple partners and paying for sex by men and selling sex by women. A dose-response relationship was seen between alcohol use and risky sexual behaviours, with moderate drinkers at lower risk than both problem and heavy drinkers.
In their concluding remarks the research team writes: “In summary, we found a very high prevalence of heavy alcohol consumption in a large probability sample of rural and urban individuals in Botswana, consistent with the results of previous venue-based studies elsewhere in Africa. We demonstrated a strong and consistent relationship between heavy alcohol use and a number of risky sexual behaviors among both men and women, including the important link between sex exchange and heavy alcohol use.
This study also confirms the associations between different risky sexual practices and intergenerational sex, and also points to other important correlates of risky sex that have not been previously studied in sub-Saharan Africa, such as symptoms of depression. The findings in this study underscore the importance of integrating policies on alcohol abuse in HIV prevention efforts in Botswana and elsewhere, and attest to the need for multipronged approaches to HIV prevention that simultaneously address the overlap of risk behaviors as well as some of the social, cultural, and structural factors that help fuel the HIV epidemic. ”
The findings of this study underscore the need to integrate alcohol abuse and HIV prevention efforts in Botswana and elsewhere, the research team concludes.
Privileges attached to alcohol and drunken behaviour
People who drink to excess, either on single occasions or regularly, are more likely than others to engage in behaviour that place them at risk for contracting HIV. They will more often be present at locations where the risk is higher and more often engage in sexual risk-taking, like having multiple partners, casual partners or unprotected sex.
Under the influence of alcohol people loose their inhibitions and have their judgment impaired and can easily find themselves involved in behaviour that would put them at risk for contracting HIV. Such behaviour can not alone be attributed to the physical effects of alcohol on the brain and the body, maybe not at all! The explanation is more likely to be of a cultural, social and psychological kind. In many societies and cultures, in all corners of the world, irresponsible or rude behaviour under alcohol intoxication is tolerated and even pardoned. With this cultural acceptance in mind, people use alcohol as an excuse to perform actions that are normally not tolerated or as an explanation of failure, like poor sexual performance. In other words, drinking gives you privileges and these privileges are accepted by others.
Another thing is that the assumption or expectation that alcohol gives a certain effect, may in itself lead to feelings of joy and happiness or violent behaviors.
Alcohol is associated with violent behaviour, including sexual violence and sexual abuse
Gender-based violence – violence committed by men towards girls and women – is one driving force behind the spread of HIV. On the other hand, we have experienced through decades and from many cultures, that violent behavior is closely associated with drinking and drunken behaviour. This is not the least the case for gender-based violence.
- Youth Violence
A report from WHO Europe in 2005 maps out the relationship between alcohol and interpersonal violence. The report outlines the following categories of interpersonal violence, with examples of research results under each
- Child abuse
Violence inflicted on and neglect of children by parents and caregivers. Excessive use of alcohol by parents in Latvia, Lithuania and The Former Yugoslav Republic of Macedonia is associated with emotional and physical child abuse.
- Intimate partner violence
Violence occurring within an intimate relationship. 33% of perpetrators and 9.5% of victims of intimate partner violence in Switzerland are intoxicated at the time of assault .
- Abuse of elderly people
Mistreatment or neglect of older people by family and caregivers. Caregiver alcohol consumption is the most significant risk factor for physical abuse of elderly people receiving respite care in England.
- Sexual violence
Including sexual assault, unwanted sexual attention and sexual coercion. 46% of perpetrators of rape in Spain have consumed alcohol prior to the attack . The WHO Europe report links alcohol to interpersonal violence by a number of mechanisms