The Intersection of Gender-Based Violence and Risky Sexual Behaviour among University Students in Ethiopia: A Qualitative Study

Abstract

Women who experience gender-based violence (GBV) are at risk for adverse sexual health outcomes, as they may be unable to fully negotiate sexual encounters. This may be especially true for females at universities in Ethiopia, where women are the minority and patriarchal norms prevail. This study explored students’ experiences and faculty’s perceptions of GBV and sexual risk behaviours at two Ethiopian universities. Individual interviews were conducted with male and female students, and focus group discussions were held with students and faculty/staff. Qualitative thematic analysis was used to explore the relationship between GBV and sexual risk and identify intervention points. Data revealed that female students at both universities are regularly exposed to GBV, which in combination with risky sexual behaviours may threaten their health. Participants (n = 126) reported a belief that women who violate traditional gender norms are more prone to violence. Substance use was reported to contribute to risky behaviours, particularly for women. Participants reported male students sometimes encourage female intoxication in order to achieve sexual encounters, resulting in coercive situations. Sexual health and GBV-related services are provided on campus, but participants highlighted ways they can be improved. In order for females to safely pursue higher education in Ethiopia, campus-based interventions focused on the intersection of GBV and sexual risk are greatly needed.

Introduction

According to the United Nations (UN Women, 2017), one in every three women suffers physical or psychological violence, most frequently by their intimate partner. Violence that occurs in an intimate relationship is called intimate partner violence (IPV). IPV is one type of domestic violence (DV), which is a broader phenomenon that also strikes other family members, including children and the elderly (Rollè et al., 2018). Women are the majority of victims of these types of violence (Smith et al., 2018). In 2008, women accounted for 70% of all victims murdered as a result of IPV in the U.S. (Policastro & Payne, 2013). Gender inequality, which is deeply ingrained in many societies, is one of the reasons why women are affected more by IPV and DV than are men (European Institute for Gender Equality, 2019). In order to recognize the importance of these power imbalances and understand the causes of violence against women (European Institute for Gender Equality, 2019), the term gender-based violence (GBV), has been used as a way to refer to this broader concept of violence that surpasses one’s private life. GBV is violence that ‘results in, or is likely to result in, physical, sexual or psychological harm or suffering to women, including threats of such acts, coercion or arbitrary deprivations of liberty, whether occurring in public or in private life’ (United Nations, 1994, art. 1, para. 1).

Beyond the individual impacts of GBV, this type of violence increases women’s risk for many health issues, making it a public health concern (Gelaye, Arnold, Williams, Goshu, & Berhane, 2009; Philpart, Goshu, Gelaye, Williams, & Berhane, 2009). Adverse health effects of GBV include not only physical injury and mental health consequences, such as depression and low self-esteem, but also higher incidence of unwanted pregnancy and sexually transmitted infections (STIs), including HIV (Gelaye et al., 2009). For example, when a woman experiences physical and/or sexual violence by her partner, her chances of acquiring HIV are 1.5 times higher than a woman who has not experienced this kind of violence (UN Women, 2017). This is partly because forced or coerced sex may limit a woman’s ability to negotiate preventative behaviours such as condom use with their partner. Studies conducted in South Africa indicated that the prevention of IPV could avoid one out of every seven new HIV cases (Durevall & Lindskog, 2014).

Gender-Based Violence in Ethiopia

Violence is a major impediment to women’s full health and wellbeing in Ethiopia (Central Statistical Agency, 2017). Rates of GBV in the country are among the highest in the world, with 59% of women experiencing physical or sexual violence in their lifetime, and one in every four women having her first sexual experience under coercion (World Health Organization, 2005; Garcia-Moreno, Jansen, Ellsberg, Heise, & Watts, 2006). The 2016 Ethiopian Demographic and Health Survey (EDHS) reported that 23% of women between 15–49 years old had experienced physical violence, and 10% were reported to have experienced sexual violence; among these women who had experienced any type of violence, only about 25% were reported to have sought help (Central Statistical Agency, 2016). One of the reasons for the high incidence of GBV in the country is the prevalence of traditional gender norms that dictate behaviours and expectations for men and women in Ethiopian society (Pulerwitz et al., 2015) and reinforce women’s submissive status (Hardee, Gay, Croce-Galis, & Peltz, 2014). In fact, both Ethiopian men and women perceive violence against women to be relatively acceptable: 63% of women and 28% of men interviewed for the 2016 EDHS agreed that certain scenarios justify a husband beating his wife (Central Statistical Agency, 2016). This acceptance was higher among less educated respondents.

Campus Climate for Ethiopian Women

Female university students in Ethiopia are highly prone to sexual violence and harassment due to their minority status on campus, patriarchal traditions, exposure to drug and alcohol use, and student experimentation with the newfound freedom and independence a university setting affords (Born, Wolvaardt, & McIntosh, 2015). Despite the growing number of females attending Ethiopian universities in recent years, females remain the minority among students, representing only 36% of undergraduates in 2016, according to the Ethiopian Ministry of Education (2016). Furthermore, in 2014, only 11% of Ethiopian university faculty (professors or academic staff) were female (The World Bank Databank, 2014).

In Ethiopian universities, high rates of sexual risk behaviours, such as unprotected sex, multiple partners, and transactional sex have been reported (Mavhandu-Mudzusi & Asgedom, 2016). University students are a high-risk group for HIV globally (Kelly, 2003; Mavhandu-Mudzusi & Asgedom, 2016), with more than half of new cases of HIV occurring among youth (15–24 years old) and resulting from heterosexual sex (Mavhandu-Mudzusi & Asgedom, 2016). Previous research also shows that students who engage in substance use tend to have multiple sexual partners (Shiferaw et al., 2014), increasing the possibility of acquiring STIs. Data from the 2015 World Health Organization STEPwise approach to Surveillance (STEPS) survey in Ethiopia indicated that 36.6% of the population aged 15–29 years currently use alcohol and 17.7% chew chat, a leafy stimulant plant (Ethiopian Public Health Institute, 2016). The survey also indicated that people in this age group are more likely to use alcohol after consuming chat. These data are consistent with those reported in another study, which found that alcohol use was the most commonly used substance among Ethiopian university students, followed by chat (Gebremariam, Mruts, & Neway, 2018).

Study rationale

Much of the research conducted to date at Ethiopian universities regarding sexual risk and violence focuses on quantitative data that report incidences of HIV and/or GBV among students (Arnold, Gelaye, Goshu, Berhane, & Williams, 2008; Berhan, Hailu, & Alano, 2011; Mavhandu-Mudzusi & Asgedom, 2016; Philpart et al., 2009; Regassa, & Kedir, 2011; Shiferaw et al., 2014; Tora, 2013). Arnold et al. (2008) found that 46.1% of the 1,330 female students surveyed in the city of Awassa reported having experienced GBV since enrolling in college. They also reported that alcohol and chat consumption by females were among the main risk factors for lifetime experience of GBV. These results are consistent with those found by Philpart et al. (2009) at the same university. Not only were the same risk factors identified, but nearly a quarter of male students interviewed reported having perpetrated GBV in the current academic year.

As for sexual risk behaviours, 42% of the students in a cross-sectional study at Hawassa University reported that their last sexual encounter was unprotected (Berhan et al., 2011). Similar findings were reported by Mavhandu-Mudzusi & Asgedom (2016), whose results from Jigjiga University indicated that only 59.6% of the sexually experienced participants’ last sexual encounter was protected. Finally, Shiferaw et al. (2014) concluded from their cross-sectional study at the University of Gondar that while students reported engaging in HIV risk behaviours, including unprotected sex, alcohol and drug consumption, and multiple sexual partners, the participants did not perceive these activities as risky. Despite the important findings from these studies, there is a lack of research assessing the relationships between GBV, sexual risks, and traditional gender norms in the Ethiopian context, and to our knowledge no qualitative studies on these intersecting constructs exist. The purpose of the current study was to explore university students’ and staff/faculty understanding of gender norms, GBV, and sexual risk, and the links between these issues. This study also sought to explore university students’ ideas for what sort of interventions they might regard as helpful to prevent these issues. Such data are necessary to understand the reasons for the link between GBV and sexual risk behaviour, as well as crucial when developing culturally appropriate interventions to address and prevent these intersecting issues (Nayak, Byrne, Martin, & Abraham, 2003). As such, this was an exploratory study of how sexual risk behaviour and GBV may intersect on university campuses in Ethiopia.

Method

Study Design

Qualitative data were collected using individual in-depth interviews (IDIs) with students and focus group discussions (FGDs) with students and faculty/staff at two Ethiopian universities. Ethical approval was given by the institutional review boards (IRBs) of both Ethiopian universities and the Johns Hopkins Bloomberg School of Public Health. Prior to data collection, the facilitator explained the aim and procedures of the study and confirmed voluntary participation, and all participants provided oral consent, including permission for audio recording. We chose oral consent so as to maintain complete anonymity in the data.

Setting and Participants

Two Ethiopian universities participated in this study. University A attracts a mixture of urban and rural students from the northern region of Ethiopia, while the University B population mostly comes from rural areas in the southern region; however, both universities host students from all over the country. These universities were selected because of their relationships with the Primary Investigator but also because they are located in different regions of the country, comprising a more diverse sample. They are also an example of a ‘first generation’ institution (University A) that is well established and a more recently created ‘second generation’ institution (University B) that is rapidly growing.

Student participants were male and female undergraduates ages 18 and older. Students were recruited via convenience sampling; information on the study was announced in classrooms and via flyers posted strategically around campus. Faculty/staff FGD participants included instructors, administrators, and/or counselling staff who were recruited through snowball sampling—participants were referred via recommendations of whom could best speak to the issues of GBV and sexual risk behaviour on campus, including faculty and staff working in the Gender Office and female faculty who serve as role models for female students.

Procedures

Local Ethiopian professionals with experience working on GBV-related issues conducted all IDIs in private locations convenient and acceptable to the participants. The interviewers were fairly close in age to student participants (20–35 years old) and were gender-matched unless the participant requested otherwise. All interviewers were trained on the ethical treatment of participants, particularly in the context of discussing sexual risk behaviour and GBV. They followed guidelines recommended by the World Health Organization for collecting GBV-related data (World Health Organization, 2001).

While there are not mandatory reporting procedures established in Ethiopia, reporting of violence/abuse was made with the permission of the participant or the friend who relayed a story during the research in order to respect the survivor’s dignity and autonomy. If the student did not want her name disclosed, she was asked if an anonymous report could be made on her behalf. Participants requiring support services were referred to the University Office of Women’s Affairs, the Dean’s Office, and/or the Student Affairs Office (depending on the nature of the abuse and the participant’s preference). The study team offered to make the initial contact on behalf of the student. All students received information about counseling services and other campus resources through a referral guide provided at the end of each data collection session.

Interview questions were divided into topics areas (e.g., romantic relationships among students, student sexual behaviour, campus climate for female students, GBV on campus (including personal experiences), and current university resources and trainings). These topics were designed to help generate content for a campus-based intervention focused on GBV and sexual risk behaviours. Questions were posed in an open-ended fashion to encourage participants to discuss and reflect on their experiences.

FGDs were conducted in conference rooms or classrooms on the two campuses and were facilitated by local professionals with experience conducting research on GBV and HIV (in the case of student FGDs) and by fellow faculty (in the case of faculty/staff FGDs). FGDs were separated for students and faculty/staff, and groups with students were separated by gender. Groups were separated in this manner so as to eliminate any potential power dynamics between males and females or between students and faculty. The discussions focused on general descriptions of the nature of sexual relationships on campus, definitions of GBV and beliefs as to what causes it, norms around sexual risk reduction behaviours, and ideas for a campus program addressing the intersecting issues of STIs/HIV and GBV. FGDs with both female and male faculty and staff explored many of the same topics as those explored with students, with an emphasis on current initiatives to address risky sexual behaviour, GBV incidents that have occurred on campus, resources currently available to female students who experience GBV, consequences for perpetrators, and ideas for an intervention for first-year students.

All interviews and FGDs were digitally recorded with the permission of the participants. Interviews lasted 30–45 minutes, FGDs took 60–90 minutes, and all were conducted in English, Afan Oromo, or Amharic, depending on the participant’s preference (although a vast majority was conducted in Amharic). Recordings were transcribed and translated to English by professional translators and/or hired local professional research assistants. No identifying information was entered in the transcribed text to ensure participants’ privacy and anonymity.

Analysis

The coding and analysis were guided by specific topics of interest to the research team that would facilitate the development of a campus-based intervention. We considered the definition of GBV and its incidence on campus, causes of sexual risk behaviour, and the possibility of a campus-based prevention intervention to decrease the incidence of both. We then used Braun and Clarke (2006)’s framework for guiding the rest of the analysis. This was primarily a deductive analysis based on our review of relevant literature and the aims of this study. The research team (including both Ethiopian and American investigators) identified initial codes. Three coders independently coded the data by topic in a multistep process. First, the IDI and FGD transcripts were read in their entirety in order for researchers to develop an overall sense of the data set and initial impressions of each pre-selected topic. Next, the three readers began assigning to the text both the initial codes and creating any new codes that seemed appropriate based on the data. Secondary codes (subtopics for each general topic area) were discussed and agreed upon. The three coders compared all codes applied to the transcripts until reaching at least 85% agreement (Gottschalk, 1995). Any discrepancies in coding were discussed by the research team until reaching consensus. Codes were then grouped into themes under each general topic area. Lastly, illustrative quotes were selected to demonstrate the findings. Atlas.ti 8 software was used to manage and code all data.

Results

A total of 70 students (34 females and 36 males) participated in IDIs. The mean age for women in this group was 21.5 (SD = 1.8; 3 missing values) and 21.6 for men (SD = 2.2; 2 missing values). The students had been studying at the university for an average of 2.5 years (SD = 1.2; 4 missing values for women, 2 for men). A total of 56 individuals participated in FGDs. Of those, 37 were students (19 females, 18 males) and 19 were faculty/staff (8 females, 11 males). The mean age of participants in the students’ FGDs was slightly higher than those participating in the IDIs: 22.5 for women (SD = 1.5) and 21.8 for men (SD = 1.9), who had been studying at the university for 3.3 (SD = 1.3) and 2.8 (SD = 1.3) years, respectively. Among faculty/staff, women’s mean age was 26.6 (SD = 3.9), and men’s was 31.2 (SD = 5.4). This is consistent with the tendency for faculty at Ethiopian universities to be quite young.

Data analysis focused on three major topic areas: (1) traditional gender norms and their link to GBV on campus, (2) risky sexual behaviours in the context of traditional gender norms and GBV, and (3) student health support and resources. Data from both universities regarding these topics presented more similarities than differences and are outlined below.

Traditional gender norms and their link to gender-based violence on campus¹

Participants from both universities, including faculty and students, shared very similar expectations regarding norms for women’s behaviour, clothing, and sexuality. These expectations seemed to align with traditional gender norms typical of patriarchal societies such as Ethiopia. Participants reported that wearing modern clothes make women appear sexually provocative, and male students may assume women dressing in modern attire are inviting sexual attention, a mind-set that was reported to sometimes lead to GBV. This was especially evident at University B, which has a more rural student population.

It [the occurrence of GBV] is because of the girls’ improper dressing, which invites men to talk to them in an abusing manner; this will facilitate gender-based violence. (male student, University B)

On the other hand, male and female students at both universities reported a belief that women who behave according to traditional norms are more respected than women who do not conform; therefore, the students believed that more traditional women are less likely to become victims of violence.

In this [university] compound, respect is not for being female; rather it depends on that specific girl’s behaviour and personality. If the girl is very serious, and if she is very much attached to her education as well as to her religion, she will be very much respected by all university communities, including her classmates and teachers. Contrary, if she is unethical and a low performer in her education and observed with different guys, she will definitely [be] disrespected by the university communities. (female student, University A)

At University B, the influence of traditional gender norms at the university was rarely questioned by students, as they tended to view men’s status as superior to women as a natural occurrence. Even female students reported this social hierarchy as natural and one to be respected. One of the implications of these gender norms is the belief that GBV is women’s fault if they defy their assigned roles:

In this campus there is freedom; if you keep your own dignity, no one will touch you. If you can work and show them your ability, if you don’t go out at an inappropriate time and place, then you will be respected. (female student, University B)

This victim blaming, or the idea that women are responsible for the disrespect or violence perpetrated against them when they do not follow the traditional gender norms, seemed to serve as a way to justify abusive behaviours.

Risky Sexual Behaviours in the Context of Traditional Gender Norms

Student sexual practices were closely tied to traditional gender norms and the experience (or fear) of GBV. The students’ accounts of risky sexual behaviours did not establish an explicit relationship between those behaviours and GBV. The presence of traditional gender norms, including victim blaming, kept some students from linking the two; they did not see a connection between men’s dominance over women as creating an environment conducive to violence and unsafe sex. Yet, some students clearly expressed a link:

Female students are influenced to have sex by their male sexual partners. Those male students who are substance abusers force females to have sexual activities. (male student, University A)

We have boyfriends with whom we go to clubs, but after I relaxed there with them until 8 pm, I return to the dorm. I trust these guys a lot, they are like my brothers, but if I stay longer there, you never know what happens, and if sex in that case happens it will be an irreversible regret. We all drink alcohol; when it gets so late we have to sleep together, maybe 7 in one room. You sleep easily being drunk and having men sleeping next to you; you don’t know what they may do to you. If sex happens, it will really have negative impact for him and for me, too. (female student, University B)

Students from both universities reported that sex is a significant part of university life, mentioning it happens with frequency both on and off campus despite prohibition of opposite sex visitors in dormitories.

Substance use.

Faculty and students both reported that alcohol and drug consumption by students can result in risky sexual behaviours, including unprotected sex and multiple partners. Students reported using alcohol and drugs with frequency when they leave campus and go into town, especially chat. The risks associated with use were thought to be exacerbated for female students, especially if regular use leads to addiction and then to sex work:

In front of University A, there are a lot of houses that provide services for chat chewing, cigarette smoking, and taking of shisha [tobacco smoked in a water pipe]. Female students who are addicted to different substances are [forced to have] multiple sexual partners to get money to buy those substances. Unless University A removes the houses that provide substances around the university, it is difficult to stop female students from doing sex for money. (female staff, University A)

Participants also commented that getting female students intoxicated is a tactic male students have been observed using to get women to have sex with them, suggesting the presence of sexual assault when substance use is involved. Participants also speculated that when male students use alcohol, they might become violent or coerce females into sexual encounters:

Most of the time males’ sexual intercourse interest is the main cause for gender-based violence. Those students who take alcohol force female students to have sexual contact.…Male students forget what they are doing after taking a lot of alcohol. (male student, University A)

Condom use.

Both female and male students pointed out that substance use can result in unprotected sex because of reduced inhibitions and the inability to make rational, healthy decisions while intoxicated. This can occur even if the substance user is aware of the risks associated with unprotected sex, such as pregnancy and STIs/HIV:

When they [students] join nightclubs, they consume too much alcohol and get drunk. Therefore, it is less likely to care for the use of a condom; they ask themselves in the morning and they regret after all. As we informally hear, [male] partners prefer sex without condoms. They let the females drink more and not to question the use of condoms. (female student, University A)

In addition to intoxication, participants reported other factors may result in unprotected sex, including a lack of information among students regarding healthy sexual relationships, STIs, HIV, and pregnancy, especially among first-year students:

Mostly unwanted pregnancy is common among freshmen students rather than experienced students. Senior students have information on the prevention of STIs. Therefore, they share information among themselves, and it is common to use condoms and other family planning methods. There is less awareness creation on the prevention of STIs, including HIV/AIDS. (male staff, University A)

Some students showed more concern about pregnancy as a result of unprotected sex rather than STIs/HIV:

Actually, students fear pregnancy and abortion more than HIV and STDs. When students come by saying their menstrual period is delayed, we test them, and they await the result with great tension by crying and hugging us as if we are telling them their HIV status. But they don’t give attention for STD and HIV. There is a gap in awareness. They assume that post-pill [emergency contraception] will protect them from STD and HIV…. (male staff, University B)

A lack of knowledge of the consequences of sexual risk behaviour seems to be exacerbated by a significant stigma among students toward women who carry or demand the use of condoms. Interviews revealed that females who carry condoms are seen as violating women’s traditional role in sexual relationships as a passive participant (whereas carrying a condom indicates planning for a sexual encounter). However, when condom use is left to male partners, female students reported that asking for a condom during an encounter might result in aggressive behaviours:

Females do not use condoms because in our context it is not common for females to think about condoms on their side. Females expect that the male will have a condom; some females check whether he has it or not, and they refuse to have sex if he fails to use a condom. However, most of the time, the decision is up to the male. She tries to trust him and to forget the issue of condom use, or he becomes angry if she asks about condoms. In order to not hurt the feelings of their partners, many females allow their partners to have sex without a condom. (female student, University A)

Concurrent relationships and transactional sex.

Engaging in multiple/concurrent relationships was another risky sexual behaviour that students from both universities reported:

When freshman students come, they start relationships with different female students. Once female students fall in love with them, they [male students] immediately go for other females. (female student, University A)

Male and female students were reported to engage in sexual relationships with multiple partners not only due to the circumstances presented above, such as substance use and seeing the university as a time to have fun, but also because they seek academic and/or financial support, especially in the case of females.

Female students can have up to three partners for different reasons: for financial benefits, for love, and for temporary sexual desire. Male students can have as many [relationships] as they want. (female student, University B)

The need for various forms of support might result in situations in which female students are especially vulnerable to abuse and violence, as reported by some students. For instance, female students who face economic challenges when they go to the university may enter and stay in abusive and coercive relationships out of financial dependence. Female students and older men from the city (‘sugar daddies’) may engage in a relationship where the older man provides financial support to the student in exchange for sex, as reported by both female and male participants. Female students are then vulnerable to unprotected sex since these older men have more power in the relationship, and the females may not be able to negotiate condom use.

There are students who don’t [have] someone to send them money or students with low-income families, so in order to do what their other friends do, to approach others looking cool and to have money for handout copies, they need money…. They have sex with an outside person like sugar daddies who are old but have money. So girls go outside, have sex with them, and return with money. (female student, University A)

Interestingly, male students at University A were also reported to reinforce this unequal power dynamic between men and women by engaging in different kinds of relationships with women depending on their age. While younger women were seen as more attractive and purer (especially first-year students), even praised because of their virginity, senior female students were considered too old by male students.

If the relationship is for sexual orgasm, most students want to have younger aged sexual partners. Senior male students want to have sexual partners with freshman female students because of their younger age. (male student, University A)

The expectation for female students to be virgins represents another aspect of how traditional gender norms play a role in Ethiopian society, further exposing female students to both physical and psychological GBV. This power dynamic may also result in first-year female students having less knowledge about sexual health and being less likely to ask their partners to use condoms.

Student health support and resources

In addition to asking for examples of the ways in which female students are exposed to STIs/HIV and GBV, both students and faculty/staff were asked about any existing resources available on campus for students experiencing these threats to health and wellbeing. Participants from both universities acknowledged the availability of student support and resources for STIs/HIV and GBV, but they also identified problems and indicated ways to improve their effectiveness. Both universities were reported (and confirmed) to have a health centre students could attend if they had STI symptoms, needed family planning services, or required other sexual health services (including condom provision and HIV testing); a gender office to act in cases of GBV; and campus police that patrol the campus, including in the evenings. Students suggested that the interventions in place at both universities are often not effective because of perceived issues related to privacy and stigma. Although the health centre offers many resources to the students, students from both universities affirmed they usually feel uncomfortable using these services due to privacy concerns:

I think most students do not like to get health services from the [university] hospital because there are students who are working in the hospital, so they don’t want to be seen by their friends. Many students prefer to use such services outside the campus in private [non-governmental] clinics. (male student, University A)

Some students reported they do not even feel comfortable obtaining the free condoms offered by the health centre due to a lack of privacy and instead engage in unprotected sex:

I see multiple posters, which promote condom utilization. Condoms are available for students. But…[the] place is not user friendly. Everyone can observe you while taking the condom. Therefore, students may not be using it. (male student, University A)

However, some students did not know about the distribution of free condoms by both university health centres. Others thought the condoms that are made available are insufficient:

Condom supply at this university is very poor; the outlets/boxes are not enough. (male student, University B)

In addition, the stigma regarding STIs/HIV is still a barrier for prevention:

I feel that students might be exposed to STI and HIV/AIDS.… If one of the partners, for example if the man urged for the use of condom, then she may feel that she is suspected of the virus or STI, so in this case I have a feeling that they might be exposed to the risk. (male student, University B)

Some students also reported that they did not need to be tested for STIs/HIV since they were only having casual relationships; they would only test if they thought it would be a long-term relationship. The lack of clear information about the services provided by the health centre and issues of privacy regarding their visits were recurrent themes at both universities.

Furthermore, faculty and students highlighted the need for better mental health services, especially to support sexual assault victims and increase GBV prevention:

I wish we had psychologists to help her [rape victim] more. But, recently, the health science college sent us psychologists periodically to consult. If we had medical doctors in the clinic, students would visit these doctors. I wish the clinics were able to attract students seeking [mental health] services. (male staff, University B)

As it is known, victim students will be [more] morally harmed than physically…. So to decrease that,…contact with psychology professionals should…help the females to recover earlier. (female student, University A)

This call for better mental health support was expressed universally by male and female students and faculty alike.

Discussion

Through qualitative data gathered at two Ethiopian universities, this study explored university students’ and staff/faculty understanding of gender norms, GBV, and sexual risk, and the links between these issues, with a further aim of exploring views about what sorts of interventions might be helpful. The results presented here suggest a relationship between traditional gender norms and increased risk of GBV and STIs/HIV, despite most participants not explicitly making this connection. Addressing the intersection of GBV and sexual risk may be more productive than dealing with these issues separately, as reported in other studies. For instance, the SHARE (Safe Homes and Respect for Everyone) Project in Uganda proposed a community-level intervention addressing these issues together, resulting in a reduced incidence of both IPV and HIV (Wagman et al., 2015). Another recent study also conducted in Uganda revealed the importance of programs focused on IPV prevention (one form of GBV) since they reduced the incidence of HIV by 33% (McKinnon & Karim, 2016).

The victim blaming discussed in this study not only reinforces the existence of traditional gender norms but also helps to disguise occurrences of GBV (Kaufman et al., under review). The opinions of students and faculty indicate a belief that the more a woman deviates from traditional gender norms, the greater her chances of suffering sexual and/or physical violence, and, therefore, she is to be blamed for such violence. This link between endorsement of traditional gender norms and GBV victim blaming has been reported in other studies (Bryant & Spencer, 2003; Sylaska & Walters, 2014). The internalization of these beliefs makes it more difficult to overcome gender role expectations that are the result of a male-dominant culture, such as that found in Ethiopia (Gelaye et al., 2009). Traditional gender norms have also been linked to STI/HIV transmission in other settings, such as Brazil, since they limit a woman’s autonomy to decide about her sexual life and reproductive health (Chacham, Simao, & Caetano, 2016).

In addition, according to a study conducted by Hardee et al. (2014), it is important to highlight that traditional gender norms increase the risk of STI/HIV infection for both genders. Stories relayed in the current study revealed a taboo around sexuality, labelling it shameful or dirty to be sexually active; students then, for example, do not want to obtain condoms even when they are available for free. In addition, the current study suggests that a young woman may depend financially on men and engage in relationships that might put her health at risk (by not using condoms or tolerating GBV). At the same time, men are expected to embrace their masculinity and show virility by having multiple sexual partners (Pulerwitz et al., 2015; Kaufman & Pulerwitz, 2019). Findings from our study are consistent with previous research both in Ethiopia (Tora, 2013) and more broadly (Hardee et al., 2014) since students, both male and female, reportedly engaged in concurrent relationships.

Nevertheless, having multiple partners is also a result of perceiving university as a time to have fun. The students’ accounts at both universities imply that having a good time may involve substance use and abuse, which could result in unprotected sex while intoxicated. Participants also reported that male students might become more violent, physically and sexually assaulting female students when under the influence of substances. These reports are consistent with other studies; in particular, Philpart et al. (2009) indicated that students in Awassa, Ethiopia who consume alcohol and chew chat are 2.79 times more likely to commit any kind violence (including GBV) compared to students who do not consume substances.

Implications for Future University-Based Programs

The data presented here reinforce the need for a campus-based intervention in cooperation with the health services already provided by the university, which would display an active role on the part of the universities to address GBV and its consequences (Bryant & Spencer, 2003; Jiao, Sun, Farmer, & Lin, 2016). As suggested in the data, better training of health centre staff and additional staff, rather than hiring fellow students to provide services, is necessary so that students can view the location as a place not exclusively related to sexual and reproductive health services, but also distribution of condoms, counselling for victims of GBV, more extensive mental health services, and even support for students with general primary care health issues, such as fevers, respiratory infections, or vaccinations. Furthermore, when dealing with the health effects of GBV, such as unintended pregnancy, STIs/HIV, and mental health issues (Gelaye et al., 2009), health professionals need to approach university students in ways that might challenge traditional gender norms in order to sufficiently address students’ risky sexual behaviours. Health and university professionals might also need to challenge their own values and cultural norms regarding, particularly endorsement of traditional gender roles, in order to effectively serve the students (Chacham et al., 2016).

Beyond the health services, the university may also benefit from addressing the intersections of GBV and sexual risk behaviour in other aspects of university life. For instance, it has been reported that perceptions and attitudes towards GBV are formed in the early years of college (Policastro & Payne, 2013). As such, first year orientation could include student discussions of how traditional gender roles are limiting and sometimes harmful for both males and females and how gender equality is beneficial for all. Nevertheless, it is worth mentioning that this paper focused on how female students are subject to and harmed by gender norms because that is what participants talked about the most. However, the focus of the data only reflects the tendency to ignore the negative impacts that unhealthy masculinity norms have on men as well as women. Actions to empower women—such as programs incentivizing more women to enrol in university and programs that help with female retention and success once matriculated—without actually addressing harmful gender norms, might result in a hostile university environment. As seen in our data, some male students feel that female students are given special privileges without seeing the need for levelling the playing field, so to speak, which creates a backlash against the women who benefit from these programs.

Limitations

While convenience and snowball sampling procedures do not produce representative population samples, we were primarily concerned with recruiting participants who could serve as key informants and provide information on the campus climate for female students, rather than participants who may or may not be familiar with GBV incidence and services. This may have resulted in biased information from participants with motivations for highlighting GBV-related issues; however, we chose this recruitment method for this initial study to ensure we were able to gather accounts of GBV. The researchers’ overall objective of designing a campus-based intervention may have influenced how data were collected, coded, and analysed. To minimize potential bias, we worked with a community advisory board at each university. The boards reviewed the interview guides and our initial results and reacted to each to ensure our interpretations of GBV and sexual risk behaviour among students were accurate. We are also aware that the personal accounts of GBV and sexual risk experience may be limited due to students’ hesitation in revealing such personal information. In addition, some of the stories told seem to conflate sexual violence/coercion with sexual harassment, even though participants were asked specifically about the former.

The study also did not account for cultural differences between students from different ethnic backgrounds. However, in choosing the two universities, we attempted to capture a range of viewpoints from various regions of the country. Even so, no particular differences between the universities were apparent. A future study might sample students by various ethnic background, region of origin, or religion. Also, University A is a ‘first generation’ university, meaning it is one of the oldest in the country, whereas University B is a ‘second generation’ university, which was established only in the past couple of decades. The level of institutional support services for students in second generation universities may not be as strong as first generation institutions given their short tenure. Despite these limitations, this study offered the opportunity to explore GBV and sexual risk behaviours in the Ethiopian university context and the chance to describe the mechanisms by which GBV may be related to poor health outcomes in this setting, particularly for female students.

Conclusion

Through stories told by students and university faculty/staff at two Ethiopian universities, this study presents a link between traditional gender roles, GBV, and sexual risk behaviour among university students. These intersecting issues have the potential to place the health and safety of all students, particularly females, at risk. However, the findings suggest several points of intervention that can be addressed to improve the campus experience for students: more attention to the harmful impact of traditional gender roles, ways in which university health services can be improved, and increased student education on the implications of substance use and sexual risk behaviours. While addressing these intersecting issues is likely a difficult task given the strong traditional gender norms prevalent in Ethiopian society, not doing so will continue to force female students to operate in a learning environment that is hazardous to their health and wellbeing.

Biography

Michelle Kaufman, PhD, is an Assistant Professor in the Department of Health, Behavior & Society at the Johns Hopkins Bloomberg School of Public Health. She is trained as a social psychologist with a focus on changing harmful social contexts that influence individual health behaviour. Specifically, her work emphasizes how gender, sexuality, and minority social status contribute to health disparities. She has researched these issues and developed and evaluated intervention programs to reduce such disparities in several countries, including Ethiopia, Nepal, South Africa, Zimbabwe, Malawi, Tanzania, Israel, and the United States. She uses both qualitative and quantitative methodologies to design, implement, and evaluate interventions conducted in settings with the fewest resources.

Graziele Grilo, MSc, is a research program coordinator in the Department of Health, Behavior & Society at the Johns Hopkins Bloomberg School of Public Health. She holds a bachelor’s degree in Political Science from State University of Campinas, Brazil, and earned her Master of Science in Women’s and Gender Studies at Towson University. Her research interests include how social and cultural contexts influence collective health behaviour and the development of public policies and advocacy work with a focus on gender, class, race, and nationality.

Ashlie Williams is a social and behaviour change professional with expertise in gender and reproductive health. Her work and research have focused on the roles of community, structural, and cultural environments in health behaviour. She has worked on research studies and programs dealing with issues such as gender-based violence, HIV/AIDS, adolescent mental wellbeing, trauma, and health policy, in diverse contexts including Ethiopia, India, Kenya, and the United States. She holds master’s degrees in Public Health and Social Work from the Johns Hopkins Bloomberg School of Public Health and the University of Maryland at Baltimore.

Christina Marea – MA, MSN, CNM, PhD (c) is a doctoral candidate in Johns Hopkins University School of Nursing. Her research interests include intimate partner violence, reproductive health disparities, refugee/immigrant health, and nursing and midwifery interventions for underserved/vulnerable populations. Ms. Marea practices Nurse-Midwifery in Washington D.C.

Lakew Abebe Gebretsadik, MPH, is an Associate Professor in Health Education and Promotion in the Department of Health, Behavior and Society at Jimma University Southwest Ethiopia. He holds a MPH in Health Education and Promotion as well as a Bachelor of Science (BSc) in Public Health and a Diploma in Comprehensive Nursing. He has ample experience in leadership at grass-root level public health service provision and mid-level health service management. His research area is reproductive health, maternal and child health, malaria prevention behaviour change and HIV/AIDs behaviour change. He is particularly interested on implementation research of these research areas. He is the principal investigator of innovating maternal and child health project funded by IDRC, Canada; Co-PI of Advancing Community’s Capacity on prevention and control behaviours of Malaria in Jimma Zone funded by USAID, Ethiopia, among others. He had been also a Country Coordinator in Ethiopia on this pilot study from Ethiopian Side.

Currently, he is a second-year PHD student in Health Communication and Behavior at Jimma University.

Shifera Asfaw Yedenekal (BSc, MPH, PhD fellow), is an Assistant Professor of Health, Behavior and Society. He was the principal investigator for two projects sponsored by the College of Health Science entitled “Bottle feeding practice and its determinate in Jimma Zone southwest of Ethiopia: a cross sectional study”, and “Media with Sexual Content and Sexual Behaviour of the university students”. In addition, he was a research assistant for a formative research project conducted in Jimma University and Wollo University in collaboration with Johns Hopkins Bloomberg School of Public Health entitled “Addressing gender-based violence and HIV on Ethiopian university campuses: formative research and intervention development”. Currently, he is a PhD fellow in Health Communication and Health Behaviour as well as a district project coordinator in the Safe Motherhood Africa project. He has published more than six articles in reputable journal with national and international colleagues.

Fasil Walelign Fentaye (MSC) is an Assistant Professor of Public Health at the College of Medicine & Health Sciences, Wollo University, Dessie, Ethiopia. After completing his bachelor’s degree from Hawassa University in Medical Laboratory Sciences, he has been working in a district health facility. After completing his master’s degree in 2012 in Health Monitoring and Evaluation, he has been teaching at Wollo University (Department of Public Health). His research interests focus on Healthcare quality, equity focused health (healthcare for people with disabilities, and people with special healthcare needs), Health Information Management, and Evaluation of Health Programs (HIV/AIDS, Tuberculosis, Malaria, etc) using a mixed-method approach.