National cross sectional study of views on sexual violence and risk of HIV infection and AIDS among South African school pupils

Introduction

In South Africa sexual violence is probably exacerbated by the country's violent past. The endemic violence is now highly sexualised and is aimed at the most vulnerable members of society.1 2 HIV infection and AIDS have spread widely as a result of unprotected and forced sex.3 4

The consequences of sexual abuse during childhood are well recognised as is the link between sexual violence and HIV infection.5^–9 In South Africa, several studies in youth have shown that they are affected by sexual violence, that there is a high prevalence of misconceptions about sexual violence and about the risk of HIV infection and AIDS, and that responses to communication about behaviour change may be less positive than expected.10^–18 We investigated the views of South African school pupils towards sexual violence and towards the risk of HIV infection and AIDS.

Methods

We based our sample on the South African 2001 census, stratifying the enumeration areas of each province into metropolitan or capital, urban, or rural. We randomly drew sentinel enumeration areas proportional to the population in each stratum, and we matched schools to each enumeration area from a list of registered schools provided by the provincial education authorities. Over-sampling in three provinces, the result of additional funding, was weighted to derive national indicators (see bmj.com).

All nine provincial departments of education gave permission to administer a questionnaire within their curriculum. The researcher in each classroom explained to the pupils that the questionnaire was voluntary, that they could stop at any time, and that answers would be anonymous. The classrooms were arranged for privacy.

Our questionnaire elicited views on, and experiences of, forced sex and was provided in nine languages: English, Sesotho, Sepedi, Setswana, Setsonga, Tshivenda, IsiZulu, IsiXhosa, and Afrikaans. We used the term “forced sex without consent,” as the equivalent word for “rape” does not exist in some languages.

With teachers absent, the researchers—mostly young female fieldworkers—read each question in the languages requested.

Views on sexual abuse included: a person has to have sex to show love; sexual violence does not include touching; sexual violence does not include forcing sex with someone you know; girls have no right to refuse sex with their boyfriends; girls mean yes when they say no; girls like sexually violent guys; girls who are raped ask for it; and girls enjoy being raped. We used three or more of these eight beliefs as a summary measure of misconceptions about sexual violence. We defined views that would put someone at high risk of HIV infection as believing that sex with a virgin can cure HIV infection or AIDS, believing that condoms cannot protect against HIV, having no intention of going for an HIV test, having no intention of telling the family if HIV positive, and intending to spread HIV if positive. We analysed risk with the Mantel-Haenszel test.19 20

Results

Between September and November 2002 we invited 5162 classes in 1418 South African schools to take part in our study. Overall, 283 576 youth agreed to participate. Their ages ranged from 10 to 22 years. We excluded those over 20 years of age, leaving 269 705 participants (average age 14.8 years). The questionnaire was returned by all participants. The non-response rate to individual questions was between 0% and 4.3% (tables 1, 2, 3).

Males were more likely than females to have misconceptions about sexual violence (table 1). The younger respondents (10-14 years) were more likely than the older ones (5-19 years) to believe that sexual violence does not include touching, that if you know someone, forcing sex is not sexual violence, and that girls have no right to refuse sex with their boyfriend. Respondents who were male or lived in a rural area were more likely to express three or more of the eight views (table 2).

Links between sexual violence and risk of HIV infection

Overall, 8.6% (weighted value based on 27 118/269 705) of respondents said they had been forced to have sex in the past year. Younger males were more likely to report this than younger females (figure). In the older age group, more females than males reported having been forced to have sex in the past year.

Proportion of children who had been forced to have sex in year before survey (percentages weighted by province)

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Respondents of either sex who had been abused in the past year were more likely to have misconceptions about sexual violence and about the risk of HIV infection and AIDS (table 2). Sexually abused youth were more likely to believe they were HIV positive (odds ratio 1.90, 1.85 to 1.92; 43.0% (36 235/84 321) who reported sexual abuse v 28.6% (52 237/182 921) who did not report sexual abuse). Respondents who had been sexually abused in the past year were more likely to have no intention of taking an HIV test, more likely to say they would not inform their family if they were HIV positive, and more likely to believe that sex with a virgin could cure HIV infection or AIDS (tables 2 and 3). Youth who had been forced to have sex were more likely to say that they would intentionally spread HIV (odds ratio 2.39, 2.34 to 2.44; table 4). This attitude did not differ between the sexes.

Table 4

Factors associated with claim among South African youth that they had forced someone else to have sex

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Overall, 33.0% (weighted value based on 88 932/268 622) of respondents thought that they were HIV positive. This response was more common in youth from rural areas. Those respondents who had never had sex (25.8%; 34 987/135 708) still feared they might be HIV positive. They were also more likely to say they would spread the infection if they were HIV positive and were more likely to believe the myth about virgins (table 3).

Discussion

South African school pupils seem to have internalised their risk of sexual abuse into misconceptions about sexual violence and about the risk of HIV infection and AIDS. Participants who claimed to have been forced to have sex were more likely to say they had forced someone else to have sex and were more likely to have views that would put them at high risk of HIV infection—for example, sex with a virgin can cure HIV infection or AIDS, condoms do not protect against HIV.

Our questionnaire was provided in nine languages and was completed by respondents in the best achievable conditions for anonymity. We have no way of knowing how many pupils exaggerated their responses or were inhibited by the proximity of peers in crowded classrooms. Although we obtained high response rates to individual questions (95.7%-100%), the brevity of our survey did not allow for detailed responses. Because of the nature of our study design, we were only able to look at associations between attitudes and sources of information on risk of HIV infection. A longitudinal study of educational initiatives would confirm beneficial effects.

Our survey reflects the situation of school pupils only. Youth absent from school at the time of the survey may have been at higher risk. The extent of sexual abuse among females may be underestimated because of those who had to leave school as a result of pregnancy due to sexual abuse.

The belief that it is not rape to force sex on someone who is known was “protective” in our model of misconceptions about sexual violence and self declared perpetration of sexual violence. This could be because youth who believed it is not sexual violence to force sex on someone known were less likely than others to say they had forced sex on someone else, since their definition of rape excluded forced sex with anyone they knew.

The apparent expectation of sexual coercion among the youth and the associated adaptive attitudes contribute to a culture of sexual violence. Males and females were affected similarly, showing a reaction to and a reinforcement of their everyday risk of sexual abuse. It is important that those responsible for educating youth about HIV infection take into account that youth may be changed by their personal experiences and environment and this is likely to condition their reaction to educational messages. We found no convincing association between attitudes and education on risk of HIV infection from a national non-governmental education programme, youth group, or church. The classroom setting seemed to be the only source of education consistently associated with fewer misconceptions. One in three youth believed they could be HIV positive. One in four of these had not even had sex, an indicator of ignorance of the mechanism of HIV infection. This failure of education comes at an important cost: youth who believed they were HIV positive had misconceptions about sexual violence and about the risk of HIV infection similar to those who had forced someone else to have sex.