Social Normative Origins of the Taboo Gap and Implications for Adolescent Risk for HIV Infection in Zambia

"Discordance serves as a novel measure and harbinger for the presence of social norms, which in this case generated a taboo gap that impeded carseeking and increased risk for HIV, particularly among adolescent girls."

Zambian Demographic and Health Survey data reveal that increased difference (discordance) between professed attitudes and measures of behaviour regarding premarital sex among adults is strongly associated with increased risk of HIV in adolescents, particularly girls. While most adults (80%) said they did not support sexual relationships prior to marriage, 50% of adult women's and 80% of adult men's reported age of first intercourse predated their age of first union, signaling that they had engaged in sex before marriage. When the level of discordance between adult behaviours and attitudes towards premarital sex increased by 10% in a given community, the risk of HIV in adolescent females rose significantly by nearly 30%. This paper addresses several questions related to the origin, manifestations, and implications of these findings: (i) Why is adult discordance in attitudes and behaviours regarding premarital sex associated with increased risk for HIV in adolescents, especially girls? (ii) How do social norms lead to distinct sexual behaviours in adolescent girls versus boys? (iii) What types of structures create and perpetuate these norms? (iv) What is the impact of these norms on care-seeking behaviour in adolescent girls and boys? (v) What types of interventions have been attempted and shown to be successful in changing harmful social norms related to premarital sex attitude-behaviour discordance? What are the benefits and drawbacks of these approaches?

To gain insight, the researchers conducted two types of analyses: a qualitative literature review, spanning the years 1990-2020, and quantitative ZDHS data analysis of four survey rounds of the ZDHS from 2001 to 2018.

Based on these investigations, the researchers suggest that the discordance is due to the reluctance to talk about premarital sex in Zambia, resulting in a situation they call the "taboo gap", where sexual behaviour is a forbidden topic, and adolescents feel unable to seek advice or sexual and reproductive health services. They suggest that girls might be more vulnerable than boys to the consequences of the taboo gap due to double standards in how people judge boys and girls who have premarital sex, reflecting the patriarchal context in which they are situated.

The analysis offered in the paper reveals that the taboo gap is rooted in harmful gender norms (social norms that specifically apply to people because of their gender) that are perpetuated by:

• Schools: Ultimately, norms regarding premarital sex were shaped in the educational sector by messages conveyed through the classroom content provided (or forbidden). These messages could have contributed to generating or reinforcing the taboo gap. The lack of support and training to teachers to teach sex education well has further impeded the quality of sexuality education.
• Churches: In Zambia, approximately 95% of the population practice Christianity. Despite most Zambian Christian churches promoting abstinence before marriage, churchgoers' actions do not necessarily follow church teachings.
• Cultural influences: Although boys and men know that their church and school advocate that they wait until marriage, sanctions are less apparent than for girls, and conversely, cultural pressures surrounding masculinity appear to create a strong pull towards behavioural dissonance from attitudes professed publicly. Furthermore, challenges like food insecurity and household poverty in Zambia may place girls in positions where they are vulnerable to sexual exploitation (e.g., child marriage, transactional sex), increasing their risk of exposure to HIV.
• Health systems: Adolescent girls may face pushback within their health systems if they seek preventative care. In Zambia, until 2005, women were not allowed to obtain contraceptives unless they had consent from their husband. The failures of the reproductive health clinics extend beyond family planning, particularly for adult women who seek information about sexual health or who are interested in learning about how to stop the spread of HIV. The dismissal and shaming exhibited by service providers may widen the taboo gap, making girls feel embarrassed about their sexual behaviour and fearful of sanctions.

To address the taboo gap, the researchers argue that successful interventions must involve a multifaceted, gender transformative approach that engages peers and stakeholders in schools, churches, clinics, and families (particularly parents) to reduce the gendered gap in HIV risk and transmission. Here are some specific ideas:

• Strengthening health education, especially though peer support: Formal education can greatly influence behaviour, so it is crucial that schools feel prepared to provide students with accurate and culturally sensitive information about sex and sexual health. However, due to discomfort on the part of both teachers and students in discussing these topics, peer health educators could be better suited to provide their peers with resources about sexual and reproductive health and to serve as a safe resource where students can seek help if they find themselves navigating exploitative or otherwise harmful relationships. An earlier study found that adolescents suggested incorporating multiple types of education (such as television programmes, pamphlets, plays) into peer health education. They also mentioned that it was important for peer educators to be trained on how to support students who are experiencing intimate partner violence or rape.
• Improving parent-child communication about safe sex: Parents typically play a large role in the way children see the world, so if parents are willing to engage in open and honest questions about sexual health, then their children may be able to seek help, advice, or preventative care when needed. Parents also play an important role in deciding what material is taught in schools, so ensuring that parents understand the importance of sex education and feel included in discussions about sexual health is crucial.
• Recognising the "Sugar Daddy" phenomenon - where girls and women engage in sexual relationships with older men in exchange for money or gifts - and addressing the complex sexual relationships that adolescent girls may be navigating without shaming them.

In discussing the study's findings, the researchers "acknowledge that there are many other issues related to provision of sexual and reproductive health in addition to the normative factors ... focus[ed] on here, however, it is important to note that a failure to address normative issues, for example by focusing only on supply-side factors, may render sexual and reproductive health programmes insufficient to meet the needs of adolescents. Even if reproductive clinics have an adequate supply of condoms, harmful norms and fear of judgement may generate a taboo gap - belied by discordance between premarital sex attitudes and behaviour - that inhibits adolescents from seeking information and care that could protect them from HIV. It is important to make sure that all levels of health care providers are comfortable addressing the needs of teens who seek sexual and reproductive health care, and that they do not approach their adolescent patients with judgement."

In conclusion: "The concept of the taboo gap may be recognised in other situations, particularly where behaviours take place in private and are publicly sanctioned and discordant from commonly held attitudes."