by Lucy Farrar^[1], School of Historical, Philosophical and International Studies, Monash University

 

Abstract

This article examines the failure of the condom as a HIV prevention device in marriage relationships in southern Africa. Amid the HIV/AIDS epidemic, the widespread neglect of condoms in marital relationships critically hinders HIV prevention campaigns. Where male control over the sexual realm has seen the male condom become largely disused, the need to understand male rejection of condoms becomes vital.

To conduct its examination, this article adopts a framework of symbology. Analysing 52 condom studies conducted across the southern African region, this approach offers insight into the way men symbolise condoms. By examining the ways men think about or symbolise condoms, we are able to obtain innovative and precise understandings for men's abandonment of condom use. Four distinct characteristics of the male condom which deter condom use become apparent through this symbology framework: symbols of pregnancy prevention; symbols of HIV infection; symbols of distrust; and symbols of female passivity. By providing concise explanations for the condom's neglect, we are more informed to direct HIV prevention approaches and condom marketing in the future.

Keywords: HIV, Gender, Condoms, Sub-Saharan Africa, Symbology

 

Introduction

We were the people who were not in the papers. We lived in the blank white spaces at the edge of print.
Margaret Atwood, The Handmaid's Tale, 1985: 57

In her popular novel The Handmaid's Tale, Margaret Atwood merged the dystopian nightmares of George Orwell's 1984 with Aldous Huxley's Brave New World to imagine a world entirely ruled by men (Atwood, 1985). Atwood's state of Gilead, located in Boston, Massachusetts, denied women the rights of employment and education, controlled women's sexuality, and women's reproductive health was held at the will of men. Atwood wrote her novel in 1985, most likely in light of the Iranian Revolution of 1979, and the strengthening Christian fundamentalism in the United States. Yet reflections of her literary vision can be seen within the gender structures of patriarchal societies across much of the world today. The jump between women's subordination throughout much of sub-Saharan Africa and the images Atwood provides, in particular, are not as far from reality as one may hope (Afray, 2004: 108).

The pace of the HIV epidemic in the sub-Saharan region, and its emergence increasingly along gender lines, is particularly reminiscent of Atwood's narrative. Women have been disproportionately affected by the HIV epidemic, both in terms of infection rates of individuals and the social burden of caring for the sick; married women are particularly vulnerable. Often economically dependent upon male partners and culturally conditioned to be submissive in sexual negotiations, married women are largely unable to protect themselves from the disease (Stein, 1990; MacPhail and Williams, 2003).

The central thrust of HIV prevention campaigns has been the promotion of male condoms. The Word Heath Organisation promotes condom use as a major preventive strategy; besides abstinence - which is 100% effective - male condom use has been raised as the greatest hope for reducing the spread of HIV. As a strategy for women in marriage, however, condom promotion remains unrealistic. Where male control over the sexual realm stands as the norm across much of southern Africa, women have become rendered largely voiceless in decisions over condom use (Pool et al., 2000). Conversely, male approval of condoms stands central to condom use outcomes. Where men chose not to use condoms, condom use remains neglected.

It becomes necessary, then, to understand male aversion to condoms. Why, in light of male control over sexual decision-making, do men generally choose not to use condoms in marriage despite the HIV risk? This article examines this question. Analysing 52 qualitative and quantitative studies on male condom use across sub-Saharan Africa, this article asks why male condoms in marital relationships have proven unsuccessful. Adopting a framework of condom symbology, it asks what male condoms symbolise, aiming to demarcate specific reasons why, across the region, condoms in marriage are consistently neglected. Though a large body of research exists on the failure of the male condom, no prior research has employed a symbolic approach to synthesise existing studies, to depict the broader neglect of the male condom across the southern African region. This is especially lacking for marriage populations. Nor has any prior research employed a symbolic framework to establish a set of criteria to understand how married men specifically symbolise condoms. Given the adoption of condoms in marriage relationships relies almost entirely on male approval, the need to provide such new and precise explanations for its disuse is vital.

This article begins by examining literature concerning married women's vulnerability to HIV. It then introduces the framework of symbology. Applying this symbology framework to a body of male condom research, the remainder of the article examines the specific ways in which condoms have been symbolised by males, and the resultant effects on condom use. In light of this symbology analysis, four distinct characteristics limiting male condom use become apparent: condoms as preventing pregnancy; condoms as associated with HIV; condoms asserting a lack of trust; and the condom's conflict with cultural values for female passivity. Each of these four symbols undermines notions of masculinity or threatens male authority in the sexual realm, limiting the acceptance of condom use.

 

Literature overview

Significant research has attempted to explain married women's vulnerability to HIV (See MacPhail and Williams, 2003: 340-42). Gender discourses pointing to women's inability to negotiate protection options in intimate and marriage relationships in particular hold significant weight. The underlying assumption of condom technology promotion is that women are willing and able participants in condom negotiation processes. For condom programs to be successful, women must be able to discuss issues of sex and protection with their husbands. Literature underlines this requirement that communication between partners is a key requirement in contraceptive practice (Ezeh, 2003; Meekers and Oladosu, 2002). In reverse, the strongest risk factor for not using condoms with the most recent sexual partner is not having talked to that partner about condom use (Pettifor et al., 2004; Maharaj, 2001).

In reality, however, throughout much of sub-Saharan Africa, sexual decision-making remains positioned largely in the male realm. Condoms are a technology 'that women may influence, but ultimately do not control' (Pool et al., 2000: 201). As Stein states, women have become the 'front lines of the HIV pandemic, not only because of their greater biological vulnerability … but also as a result of social, economic, political and cultural conditions' (Stein, 1990: 451). Weiss et al., among others, describe the spread of HIV/AIDS as following a sort of 'gender fault-line,' in which the societal disadvantages that women disproportionately face aggravate their risk to infection (Weiss et al., 2000: 237). Such arguments assert 'structuralized gender' as the basis of women's vulnerability; that the risk of HIV infection for females does not begin with pregnancy, nor does with a single sexual act, instead 'the real causes are inherent in the social and economic pressures that leave women with fewer options and little influence on decisions that ultimately determine their place in society' (MacCormack, 1988: 677-78).

Following Rivers et al., women's limited authority in condom use decisions is manifested in two areas: first, through women's economic dependence on men, limiting options for safe sex behaviour, and secondly through power stereotypes 'that inform expectations of female sexual behaviour…and render many women sexually passive' (Rivers et al., 2002: 277). On the first account, women's economic vulnerability has emerged as a consequence of their 'disempowered femininity,' which has left women unable to control household economics and consequently limits women's authority in decision-making, including in the sexual realm. The socialised passivity of women in intimate relationships on a second account moulds women into passive participants in relationships. As Lyncha et al. suggest, women are expected to be sexually ignorant, and those who do demand the use of prevention measures (such as condoms) are seen as assertive and unfeminine (Lyncha et al., 2008).

It is within this context of women's gendered vulnerability to HIV that this article sits. Recognising men's control over sexual decision-making has left married women critically vulnerable to HIV infection, the remainder of this article examines why men chose not to use condoms in marriage despite HIV risk. It does so by looking to the symbols that condoms represent.

 

Condom symbology framework

Multiple studies have demonstrated that condoms are socially mediated, value-laden objects that reflect diverse peer, family and community norms (Kaler, 2004; McNeill, 2009; Rodlach, 2006). Such findings reject the assumption that knowledge about condoms will alone translate into behaviour change. Rather, it reinforces that people's perceptions of what a condom means will influence how, when and whether they use them (Nixon et al., 2011: 215).

The theoretical foundation of a symbolic examination thus rests on the idea that people act toward things on the basis of meanings (Ulin, 1992). These meanings are said to be derived from socialised understandings - that is, the understandings of stimuli such as norms, attitudes, values, sanctions and experiences - which are informed by people's interaction with the things around them. Because interaction takes place within a cultural context, the process inevitably becomes one of interpretation, whereby 'individual actors transform meaning[s] in the light of their particular situation' (Ulin, 1992: 68). As McNeill et al. explain, the symbolic framework provides 'insight into how people make sense of norms and values…[and apply] these norms and values onto objects in a symbolic form' (McNeill, 2009: 364).

Applied to condom use behaviours, a symbolic perspective looks at how the symbols which condoms hold interact with health promotion campaigns. Several studies have established that condoms are socially mediated, value-laden objects that reflect diverse peer, family and community norms; and do not necessarily correlate with safe sex campaigns (see Kaler, 2004). This approach suggests that knowledge alone about condoms does not necessarily translate into safe behaviours. Instead, it is people's perceptions 'of what a condom means, [which] is more acutely influencing how, when and whether they use them' [emphasis added] (Nixon et al., 2011: 317).The failure of condom campaigns, in such light, can be linked to its failure to engage with symbols that condoms inherit. The aim of this article is to identify what these symbols are.

 

Methodology

This research employs the symbolic approach advocated above to conduct a secondary source analysis of condom studies.

Search strategy

Relevant research concerning condom acceptance and use behaviours was identified by searching the medical and social sciences databases for primary research material. A total of 12 research databases were searched for publications from 1980 through to 2012 (when this research was conducted), with key articles obtained primarily from expanded academic ASAP, MEDLINE, ProQuest, and Scopus. A complete list of the databases searched is included in Appendix 1.

To ensure that all relevant studies were included, the search terms remained wide. These were 'HIV or AIDS', plus 'marriage or long term relationships', plus 'condom' anywhere in the title or abstract. Studies were eligible for consideration in this review if: (a) the focus of the study was condom (dis)use in marriage, or in long-term and intimate relationships; and (b) the area of study was sub-Saharan Africa.

Selection criteria

The review included all peer-reviewed studies investigating condom use in marriage. Longitudinal studies were seen as particularly valuable as they enable the understanding of potential behavioural changes over time. Studies with methodological weaknesses arising from small samples, weak data analysis, or minimal qualitative data were included only when they provided insights not available from more rigorous studies. Qualitative studies were particularly desired as these provided the foundations for identifying key associations/key words that consistently emerged; that in turn formed the symbolic categories raised in this article. Studies were excluded from the analysis if condom use and acceptance explanations were insufficiently described, or condom use was only a minor element in the study, and therefore the study did not contribute important information to this review. A focus on why males in particular accepted/rejected condom use in marriage was required, but this was accepted from both married male and married female based explanations.

Overall, 28 qualitative, three quantitative, and 21 mixed methodology studies were included in this review (See Appendix 2). Where keywords or narratives describing reasons for condom neglect emerged from the data consistently across the research region, these formed the basis of what this article defines as symbols. When ten or more studies referred to a particular symbol, this was criteria for inclusion as a key symbol within this article. Ten articles represent 20% of the data base; rigorous enough to ensure against distorted interpretation of data yet broad enough to provide scope for multiple symbolic categorises to be identified.

Methodological considerations

Regarding the methodological basis of this research, three key factors should be considered when evaluating the research outcomes. These are: (a) the nature of self-reported data; (b) the categorisation of primary (largely quantitative) data into secondary data (symbolic) groupings; and (c) the comparability of cross-cultural findings.

First, most research on condom use has used self-reports, collected via self-completion questionnaires or verbal testimony. Several also used group discussion situations to collect data. Married women's reports reflect female perceptions, and hence may provide only a partially accurate portrayal of condom-use behaviours, as they are affected by social discourses and expectations. Equally, married men's reports are affected by male perceptions and self-enhancing biases: the research demonstrates that masculinity largely rests upon notions of power and authority in sexual relations. Thus, in this review of mainly self-report studies, results should be tempered by the notion that women tend to have a negative bias, while men have a positive bias of men's role in condom use.

Few studies collected women's and men's reports together. Information from both parties can provide a more complete picture, although the delicacy of the topics raised - of sexual intercourse, condom use, infidelity, and HIV - and in this particular research setting, having both men and women in the same study setting, may hinder, rather than improve, data reliability.

Secondly, providing a secondary analysis of primary data does have limitations. Ascribing symbolic categories to studies based on the presence of particular words or phrasings allows for misinterpretation or manipulation of data sets. As outlined above, however, the need for ten or more studies to exhibit a particular theme before credited as a 'symbol' does work to limit this bias. It also likely that for some relationships condom-use behaviours may be founded upon other factors such as peer approval, education, social class, age, access, and social norms. The scope of this research prohibited the ability to look further at these correlations. Thus, it should be noted that the findings reported may mask more complex relationships, beyond symbols alone.

Thirdly, the geographically large scale of the research allowed for a broader image of condom use/disuse across the sub-Saharan region to be depicted. Given the similarly of HIV transmission routes across this region, this approach holds validity. The complexity and variety of cultures with this region, however, does call for caution. Though the majority of communities operated under patriarchal systems, certainly not all do.

 

Analysis

Employing the methodology described above, four key symbols consistently limiting male condom use become apparent: condoms as preventing pregnancy; condoms as associated with HIV; condoms asserting lack of trust; and condoms conflicting with cultural values for female passivity. The remainder of this article provides an examination of each of these four symbols progressively.

Symbol 1: Pregnancy prevention

In sub-Saharan African societies, one of the greatest deterrents to condom use is its association with fertility prevention. The limited success of family planning programs in sub-Saharan Africa is in large a reflection of powerful social and cultural constraints on any effort to reduce fertility; the condom has a contraceptive function, even when that is not the reason for using it (Heise and Elias, 1993: 941). For married couples, it is culturally expected that they will have children; the prospect of having no children thus more often conflicts with, or outweighs, the value of condoms for HIV prevention (Ulin, 1992: 60-61; Maharaj and Cleland, 2005: 331). Ampofo's study on the Akan people of Nigeria's attitudes to childbearing, for instance, found that women were honoured by their husband's family for 'giving them children,' while a male partner frequently bestows public honour to his wife at the time of the 'out-dooring' of a newborn baby. In contrast, infertile men were given the name kote krawa, meaning 'inadequate penis,' and infertile woman were termed bonin, a term used to describe salty water where fish cannot survive (Ampofo, 2001: 199-200). Cladwell and Cladwell in particular ascribe the significance of large families to the paramount importance on lineage in African societies. Lineage survival relies on a wife's ability to produce large families, which in turn represents male fertility and power (Caldwell and Caldwell, 1990: 120). Where children have likewise become culturally seen as sources of labour and ensuring economic survival and wealth of the family in many sub-Saharan societies, one's fertility holds an important function (Takyi and Dodoo, 2005: 254).

In such contexts, barriers emerge from the condom's association with family planning. In Cleland and Iqbal's multi-country study, condom use for contraceptive purposes was reported at 12% among populations in Cameroon, Zambia, Namibia and Tanzania (Cleland and Iqbal, 2006: 20). Limited interest in pregnancy prevention was likewise apparent in Ryder et al.'s study, with only 24% of respondents asserting it would matter 'very much' if they became pregnant. In comparison, 76% wanted more children (Ryder et al., 1999: 468). In the above examples, even if a condom is not intended to protect against pregnancy, normative associations of condoms, signifying its family planning properties, inherently serve as barriers to its use.

Symbol 2: HIV stigma

Symbolic associations of condoms with HIV infection likewise act to prevent condom use. HIV is largely stigmatised throughout sub-Saharan Africa. The 'People Living with HIV Stigma Index', which examines the way stigma and discrimination manifest in the daily lives of people living with HIV, illustrates this point (United Nations Programme on HIV/ AIDS, 2012). High numbers of respondents across sub-Saharan Africa showed large degrees of socialised stigma towards infected individuals, and those infected reported shame, guilt, suicidal thoughts, and blame as common feelings. For Rwanda, for instance, over 50% of respondents experienced verbal abuse, 36% physical harassment and 20% had been physically assaulted (United Nations Programme on HIV/ AIDS, 2012). 65% stated unemployability or reduction of income, and 88% were not allowed access to family planning clinics because of their HIV status. A study by the Joint United Nations Programme on HIV/AIDS (UNAIDS) in 2010 showed similarly that individuals infected with HIV, as well as known 'risk populations,' such as sex workers, experience high degrees of HIV-related discrimination in their family homes. Almost 50% of respondents reported negative attitudes or felt ostracised by family members (United Nations Programme on HIV/ AIDS, 2010). Stigma and discrimination against HIV was also found to impeded use of health care services. Country progress reports from Lesotho, Mozambique and Senegal all highlighted that social stigma existed around using HIV testing services, which led to the neglect of HIV testing by sex workers and young men in particular.

In such contexts, condom messages may be unintentionally contributing to an increased risk of marital HIV by associating condom use with HIV infection. The previous three decades have seen the condom increasingly promoted throughout sub-Saharan Africa as a method to reduce the risk of HIV. In doing so, associations of condoms with HIV have become ever more normalised. Pervasive HIV awareness campaigns by governments, donors, and religious institutions have positioned HIV protection with moral health messages. The current approach of the US President's Emergency Plan for AIDS Relief (PEPFAR), as one example, targets condom use at identified high-risk groups such as commercial sex workers, promotes abstinence till marriage, and focuses condom provision on youth who are identified as engaging in or at high risk for engaging in risky sexual behaviours (President's Emergency Plan for AIDS Relief, 2012).

As a result, associations between condoms and HIV have emerged as a key barrier to condom use. A dilemma arises between avoiding the stigma of HIV while maintaining protected sex acts. In Pullum et al.'s study examining condom use in marital relationships across southern Africa, widespread disapproval of condom use was found. Despite the majority of respondents identifying condoms as a method to avoid HIV infection, they strongly associated condom use with HIV infection (Pullum et al., 1999: 460). A study on the outcome of PEPFAR's policies in Zambia in particular reflect the limitations of the prevention campaign, which found 'targeting condoms only to the highest risk groups [has]… associate[ed] them with commercial sex workers and other stigmatized groups…' and in doing so deprived women of an otherwise plausible negotiating tool (Gordon and Mwale, 2006: 70). Lyncha et al.'s survey on male taxi drivers in South Africa likewise found that men did not object to their wives requesting the use of condoms for hygienic reasons during menstruation, but strongly objected to requests to use condoms for HIV protection (Lyncha et al., 2008).

Symbol 3: Distrust

The association of condoms with infidelity likewise emerged as large impediment to male condom use in marriage. The significance of unprotected sex in long-term relationships stands central to the male condom's neglect; 'the willingness to engage in unprotected sex has become a cultural marker of intimacy' (Heise and Elias,1995: 941). Studies have shown that higher levels of love and commitment as well as longer and more serious relationships are associated with lower levels of condom use (Ezumah, 2003: 92). One of the principal findings to emerge from AIDS research is that for both women and men, there is far greater willingness to use condoms in casual relationships, with prostitutes, or with casual sex partners than with stable partners or spouses. As an example, Heise and Elias's study found sex workers encouraged condom use with their clients, yet were unwilling to use them in their private lives (Heise and Elias,1995: 943). In Agha et al.'s study, across southern Africa, condoms were used at the beginning of a sexual relationship. However, use ceased as the relationship becomes more stable. As a rural Tanzanian women summed it: 'once you are used to each other there is no need for a condom' (Agha et al., 2002: 8). A respondent in Pullum et al.'s study likewise highlights the issue: 'the wife is using family planning methods, there is no use of using the condom…the condom should be used outside the marriage, not in it. If you find someone using condoms, he will not be using them at home' (Rural man, Kenya) (Pullum et al., 1999: 460). In Eritrea and Zimbabwe, more than 40% of women reported trust of their partner as a reason for not using a condom. For men, between 47% and 73% of respondents indicated trusting one's partner was the most important reason for not using a condom with a marital partner (Pullum et al., 1999: 460). In each case, where trust is valued in marriage relationships, condom use is widely avoided.

In the above context, the introduction of condoms into established relationships such as marriage has become exceedingly difficult and seen as undermining the fabric of intimate relationship. Across the sub-Saharan region, condoms are represented as too aggressive or accusatory for relationships based on love (Pullum et al.,1999; Gausset, 2001). As Agah et al. found, condoms symbolise emotional distance and a lack of romantic involvement (Agha et al., 2002). Sobo' s work highlights in particular that in committed, monogamous relationships, 'condom use is interpreted as insulting, and suggestive of infidelity, lack of love and disrespect from partners' (Sobo, 1993: 478). Sobo further suggests 'condomless sex' has emerged as 'an adaptive and defensive practice [which] maintain[s] desired, idealized images of partners, relationships, and selves' (Sobo, 1993: 478). People want to appear as serious, responsible, faithful, and they want a relationship founded on trust.

Furthermore, within marital relationships, suggesting condom use was seen as synonymous with being untrustworthy oneself. Asking to use a condom is tantamount to not only accusing a partner of being unfaithful, but also to admitting one's own infidelity. Coggins et al.'s study on sexual protection devices in Zimbabwe highlighted such associations (Coggins et al., 2000). As a Zimbabwean farmer stated: 'if I start using a condom with my wife she will ask: 'Why all the other days have you not been using a condom my husband, why now? We are not doing this for child spacing, so why are we doing this?' (Coggins et al., 2000: 243). Pool et al. likewise found even if it was in a woman's interest to use condoms, for protection or child spacing purposes, she may be reluctant to actually use it: 'as soon as they see you with a condom they know you are bad, that you are promiscuous' (female, Uganda) (Pool et al., 2000: 201). Responding to a question about whether his wife had ever asked him to use a condom, another man stated in Pool et al.: 'How can she? Is she crazy? A woman asking her husband to use a condom is putting herself in the position of a whore. What does she need a condom with her man for, unless she is flirting around outside the married house?' (Pool et al., 2000: 201). Such requests could furthermore form grounds for divorce, because it can be assumed such women are not trustworthy: 'women who carry condoms in their handbags are prostitutes: a wife with condoms has a license to have sex with other men' (Pool et al., 2000: 202). A condom's association with infidelity has become all the more critical in the era of HIV/AIDS, when sexual infidelity is tied to a deadly disease. In every case, where the condom was linked to distrust, its use was avoided.

Symbol 4: Female passivity

The perception that requesting condom use is 'unfeminine' is a major barrier to condom use. Across condom acceptability studies, dilemmas arise between the construction of women as passive participants in sexual relationships and their responsibilities in sexual protection. Women have been broadly socialised as the instigators of safe sex behaviour, and held largely responsible for protection against their husband's infidelity. Where women have become socialised as instigating condom practice, decisions concerning safe sex measures have accordingly been constructed as external to the male domain; and masculinity has become associated with rejecting condom use (Mantell et al., 2009; Maharaj, 2001). Within this context, key barriers to condom use arise. At the same time as being held responsible for HIV prevention, throughout the sub-Saharan region, women have been socialised as sexually passive, agreeable and subordinate. Requesting condom use is perceived as unfeminine and women who do engage in condom negations with their marital partner are in many instances perceived to threaten their masculinity. As a respondent in Maharaj and Cleland's study shows, female authority over sexual decision-making is an unfavourable trait: 'I think it is important for the girl to follow the correct protocol. If it the girl makes the move I get worried. I feel like she is too experienced' (Maharaj and Cleland, 2005: 232).

Associations of condoms with 'loose' women act as further barriers to condom use in marriage. As Maharaj and Cleland found, there is a common perception that women who request condoms are 'ready for sex': if a girl carries a condom she is 'seen as a slut' (Maharaj and Cleland, 2005: 232). Matshalaga's study likewise addressed the perceptions of condom use in marriage among Zimbabwean couples, and found most men use condoms for 'hit and run' episodes, rather than for use with their wives (Matshalaga, 1999: 87-88). As a male respondent stated: 'if my regular partner gives me a condom, I cannot accept it. This means she is a prostitute.' A male participant in a Zambian study similarly stated: 'by using a condom, my wife is demonstrating a liberation I am uncomfortable with' (Matshalaga, 1999: 87-88). In the above contexts, where cultural values for female passivity conflict with condom symbols of 'unfemininity,' condom use has been largely neglected.

 

Conclusion

The male condom forms the cornerstone of HIV prevention campaigns across southern Africa. As the death toll from the HIV epidemic remains staggering, and this is increasingly so within married populations, the acceptance of condoms in marriage stands critical. It is especially within marriage demographics, however, that condom use has become largely neglected. Where male control over sexual decision-making has rendered women largely voiceless in condom negotiations, and positioned men at the centre of condom use outcomes, the condom has been largely abandoned in marriage relationships.

The purpose of this article was to examine why the male condom has been neglected as a HIV prevention device in marriage. Recognising male control over the sexual domain, this article conducted a symbolic examination to understand the way men have come to perceive condoms in marriage contexts. By understanding what the condom means in the context of men's lives, we were more succinctly able to demarcate why there is apprehension to its use. This innovative framework of condom symbology identified four specific symbolisms leading to condom neglect: its links to preventing pregnancy; its stigmatisation of HIV infection; its association with distrust and promiscuity; and its conflict with cultural values of female passivity. Each symbol can be seen as a reflection of the gender relations throughout the sub-Saharan region at large. Where male condom chacteristics undermined ideas of masculinity, as in the case of the symbols 1 and 4; where they reflect immorality and suggest disease, as in the case of symbol 2; and where they provide women with greater sexual freedom which threatens men, as in the case of symbol 3; their use has been largely abandoned. Though not an exhaustive explanation for the failure of the male condom in marriage contexts, and though undertaking a secondary analysis of primary data does provide scope for misinterpretation and simplification, through engaging in such a symbolic analysis we are equipped with specific insight into men's disuse of the male condom. In turn, we are provided with a 'checklist' for what the male condom must overcome if it is to be accepted by married men in the future.

Given the very real urgency to understand better the barriers facing HIV prevention options in the context of sub-Saharan Africa's HIV epidemic, including the key option of the male condom, such specific findings enable us to inform succinctly HIV policy approaches and male condom marketing in the future. As final conclusions, this article thus firstly suggests the need to reorient market approaches of the condom away from messages the symbols identified in this research. Marketing campaigns will continue to be needed to support wider acceptance of condoms within the evolving context of HIV in Africa. Within this task, the specific messages attached to the condom should move away from assertions of preventing pregnancy or suggestions of HIV, and work to combat the associations of condoms with distrust in intimate relationships or unfemininity. Short of long-term 'strategic' changes aimed at unravelling the uneven gender relations of sub-Saharan African societies, this more immediate and 'practical' approach may see key barriers to condom use start to be overcome.

More broadly, this article has also indicated that there is merit in applying a symbology framework to understanding condom (dis)use. Through the symbology framework applied, four new and succinct explanations can be offered to explain the consistent neglect of the condom across the southern African setting. Beyond previous structural explanations of socio-economic factors, affordability or access, this approach has been able to focus specifically on men's neglect of condoms. It has also been able to synthesise data, covering the southern African region, to offer four precise explanations for condom disuse. This article thus secondly suggests that future studies continue to use symbolic approaches to understand condom use behaviours. In doing so, policy makers and medical practitioners alike may be better informed to direct HIV prevention campaigns, including that of the male condom, towards more positive associations in the future.

 

---

 

Acknowledgements

I would like to pass on my foremost thanks to my research supervisor, Craig Thornburn, whose assistance and willingness to support my project allowed me to pursue my own research interests and ideas; at an undergraduate level this was a wonderful privilege. I likewise wish to sincerely thank Adam Clulow, who, over my several years at Monash University, has continued to offer his much trusted guidance and encouragement. My gratitude to him is certainly ongoing. My sincere appreciation goes also to Alison Farrar, for her on-going support since day one, and to my parents, for feeding, sheltering, and keeping me warm when these have sometimes felt the least of my priorities.

 

Appendices

Appendix 1

List of databases used:

Brill online, Electronic journals and newspapers on Africa, Expanded academic ASAP, Informit, Jstor, MEDLINE, POPLINE, ProQuest, Sage, Scopus, SA ePublications, SpringerLink

Appendix 2

Qualitative, Quantitative and Combination studies:

Study Type (total studies: 52)	Quantitative (total: 3)	Qualitative (total: 28)	Mixed Methodology (total: 21)
Small (sample size < 50) (total: 18)		Larson, 1989; De Bruyn, 1992; Heise and Elias, 1995; Campbell, 1995; Van der Straten et al., 1995; Schoepf et al., 1998; Susser and Stein, 2000; Ampofo, 2001; Gausset, 2001; Ezeh, 2003; Saul et al., 2004; Agadjanian, 2005; Lyncha et al., 2008	Caldwell and Caldwell, 1990; Varga, 1997; Davidoff-Gore et al., 2011; Macalusoa, M and Demanda, 2000; Mbizvo et al., 2012
Large (sample size >50) (total: 34)	Adetunji, 2000; Latka et al., 2000; McGrath et al., 2000	Ulin, 1992; Rwabukwali et al., 1994; Adeokun et al., 2000; Pool et al., 2000; Bledsoe, 2001; Zulu et al., 2002; Ezumah, 2003; MacPhail, and Williams, 2003; Pettifor et al., 2004; Meekers, and Richter, 2005; Tassiopoulos et al., 2006; Cleland and Iqba, 2006; Parikh, 2007; McNeill, 2009; Schuler et al., 2011	Worth, 1989; Orubuloye et al., 1993; Ray et al., 1995; Musaba et al., 1996; Pullum et al., 1999; Matshalaga, 1999; Agha, 2001; Maharaj, 2001; Welsh et al., 2001; Agha et al., 2002; Greig, and Koopman, 2003; Glynn et al., 2003; Pettifor et al., 2004; Maharaj and Cleland, 2006; Aggleton et al., 2011; Winskell et al., 2011

 

Notes

[1] Lucy Farrar is a final-year Arts (Hons) student at Monash University. In 2012, Lucy completed her Honours dissertation in International Studies for which she won the prize for Best Thesis and the prize for Best Honours Student in International Studies. She also won a Faculty of Arts Writing Up Fellowship to assist with publication in Reinvention. This year, she attended the inaugural International Conference of Undergraduate Research as part of the Warwick-Monash partnership and won the prize for best conference presentation for her talk, entitled 'The Potential of the Female Condom in Southern Africa'. She hopes to pursue her interest in women's health at a postgraduate level in 2014, focusing on HIV.

 

References

To cite this paper please use the following details: Farrar, L (2013), 'Why Men Don't Use Condoms in a HIV Epidemic: Understanding Condom Neglect through Condom Symbology', Reinvention: an International Journal of Undergraduate Research, BCUR/ICUR 2013 Special Issue, http://http://www.warwick.ac.uk/reinventionjournal/archive/bcur2013specialissue/farrar/. Date accessed [insert date]. If you cite this article or use it in any teaching or other related activities please let us know by e-mailing us at Reinventionjournal at warwick dot ac dot uk.