March 30, 2005

VI. Especially Vulnerable P ersons

In order to investigate the impact of abstinence-only programs on young people's right to information, Human Rights Watch interviewed a wide range of young Ugandans about their sexual attitudes, intentions, and behaviors, as well as their knowledge about HIV/AIDS prevention.Interviewees included boys and girls, both in and out of school; children orphaned by AIDS; young people affected by war and civil conflict; and young men having sex with men.These interviews revealed that for many segments of the Ugandan population, including some of those at highest risk of HIV, promoting abstinence to the exclusion of other messages violated their right to information and to protect themselves from a deadly disease.[151]

Sexually active young people

Despite numerous claims by proponents of abstinence-only programs that young Ugandans are increasingly "choosing to abstain," sexual activity among young Ugandans has in fact increased since the mid-1990s.[152]In 2000, 27 percent of single Ugandan girls aged fifteen to twenty-four reported having sex in the past year, compared to 22 percent in 1995.While the percentage decreased slightly among boys (from 33 percent to 31 percent), an increasing percentage of sexually active young men are reporting non-regular partnerships (from 55 percent in 1995 to 59 percent in 2000).Close to one-third of young sexually active Ugandan men reported having two or more sexual partners in 2000.

As noted above, Ugandan girls who are married or in other committed relationships are not safe from HIV.Girls typically marry men who are much older than they are, and who have been sexually active for a long period of time.In some cases, their husbands are already married and are moving on to their second or third wife.Even in non-polygynous marriages, extra-marital sex is much more common among men than among women; some 12 percent of married Ugandan men reported extra-marital sex in 2000, compared to 3 percent of women.[153]Absent significant changes in the sexual behavior of men, therefore, HIV prevention messages that encourage young women (and men) exclusively to "abstain until marriage" provide a false sense of security.

The experience of Mary A., twenty-four, illustrates many of these points.Mary A. told Human Rights Watch that she met her first husband when she was sixteen, and that she entered a polygynous marriage without perceiving that she was at risk of HIV.

When I was sixteen, I met my first boyfriend.He was married.He promised me I could be his second wife, and I accepted.After my studies, I went and stayed with him.We had a baby boy, and he [the baby] died when he was one.At the time, I didn't even imagine having a son who could die of AIDS.Then, the following January, AIDS killed my husband.[154]

Mary A. said that as a student, she was taught to abstain until marriage:

We used to go for seminars on HIV/AIDS in vocational school.They tried to tell us what HIV is, how someone can get it, and how someone can avoid it.The message was, abstain from sex, and if not, have protected sex and be faithful.But with my first husband, I asked if he had any tests.I said, are you sure you're HIV-negative?I trusted him.I'm sure I got it from him.

Insisting that her husband take an HIV test may have helped Mary A. avoid infection.But testing is not a complete solution, particularly for women who marry men who are unfaithful or have multiple wives.HIV prevention programs need to be forthright with young women about the risk of HIV in marriage, and also target sexually active young men-both married and unmarried-with information and condoms so that they will be less likely to transmit HIV to their wives.

Some argue that encouraging men to abstain until marriage would help people like Mary A. avoid HIV infection.But both quantitative and qualitative data suggest this strategy by itself would not be enough.As noted above, close to one third of single Ugandan men reported being sexually active in 2000, roughly the same percentage as in 1995.Of these, close to one-third reported having two or more partners.Like girls, boys can be driven by situations of extreme poverty into having sex with older partners who promise money and gifts in return.Fortunately, condom use among sexually active young men rose significantly in the late 1990s, with 62 percent in 2000 reporting they used a condom the last time they had sex with a non-regular partner compared to 40 percent in 1995.In this context, it is difficult to comprehend the current Ugandan strategy of not promoting condom use to young single males.

James K., seventeen, told Human Rights Watch he began living on the street when he was fifteen, shortly after his parents died of AIDS.Soon after, he met a "sugar mommy" who gave him a place to stay in exchange for sex and other favors.

I had a sugar mommy, she was thirty-two.She found me in the street.I know how to drive, so I used to drive for her.After a while, she began taking me to her place and making me her lover.She spent three and a half months with me.I didn't like staying with her and having sex with her, but I had nowhere else to go.She was acting as my guardian.[155]

James K. said he always used condoms with his "sugar mommy" because, as he put it, "I'd gone to a seminar before, and they said whenever you have a woman you should use condoms."He said he has been tested for HIV seven times and is HIV-negative.

Peer educators interviewed by Human Rights Watch underscored the inadequacy, as well as the potential harms, of targeting young people with strict abstinence messages and denying them information about safer sex options.Moses T., nineteen, put it this way:

Abstinence is a good thing, but at times this message is too late for most of the groups we work with.Even for the "good" kids in school, many have strict parents and are not allowed to have boyfriends and girlfriends.So any chance they get, they sneak away and have sex with whomever.This is driving the problem.Abstinence until marriage can be possible, but only for a few.[156]

A social worker at a youth drop-in center in the Kawempe Division of Kampala told Human Rights Watch, "Each group we work with needs its own message. . . . Some ages and some groups will not listen to abstinence, and we need to accept that as reality and work with them."[157]A nurse in the same center added, "The condom message is working.We see the number [of condoms] being used and demanded has grown, plus we've seen a reduction in the number of STIs here at the center."[158]

Providers of youth-friendly services added that judgmental attitudes toward premarital sex dissuaded young people, especially girls, from seeking health services and information.Abstinence-only messages, linking pre-marital sex with immorality, are only likely to make things worse."The girls are involved in sex when they are young, so when they go to health centers they get judged a lot," said the social worker cited above."So they don't go, and it's easier for men to deceive them because they lack information."

Orphans and children affected by AIDS

Uganda is home to nearly one million children orphaned by HIV/AIDS in addition to children whose parents are sick and dying from the disease.[159]While some are taken in by relatives who care for them, others suffer abuse at the hands of their caretakers or are forced to establish child-headed households.Still others end up on the street, where they may engage in hazardous labor, including sex work, to survive.Without parental support or family income, orphans may be withdrawn from school and forced into severe economic hardship.Many of these abuses increase vulnerability to HIV infection.Children orphaned by AIDS may be more vulnerable to abuse and eventual HIV infection because of AIDS-related stigma and discrimination.

A recent global report on children orphaned by AIDS produced jointly by UNAIDS, UNICEF, and USAID concludes, "Because sexual activity (as well as substance abuse and other risky behavior) often begins during adolescence, it is critical to provide comprehensive sexual health education and services to reduce the risks-often heightened for orphans-of unwanted pregnancies, coerced sex, exploitation in commercial sex, and transmission of sexually transmitted infections. Programs must provide information on health behaviors and the life skills that adolescents need to protect themselves."[160]

Groups working with orphans and children affected by AIDS in Uganda told Human Rights Watch that abstinence-until-marriage messages were both irrelevant and potentially dangerous.One youth activist working in the Kawempe neighborhood of Kampala said:

I wish those who preach abstinence would come down to the slums and see how people are living.Abstinence is a message for the elite; it has no place in the slums.These girls [orphans] live five to a room.There is no supper for them.The man outside says he will get her money and a place to sleep.Now, what is she going to do, abstain?These orphans need assistance, services, and access to protection, not judgmental messages.Better to be delivering services than abstinence messages.Around here, they are a waste of time and money.[161]

A member of an outreach team organized by the AIDSInformationCenter (AIC) in Mbale explained that messages promoting abstinence and delayed sexual debut were commonplace in Uganda, but they had little resonance with the communities in which the team worked.Few orphans had the choice of abstaining from sex, he said, as poverty and hunger routinely drove them to engage in paid sex.[162]

A seventeen-year-old orphan living in the Namatala neighborhood outside Mbale echoed this view, saying:

For those girls who don't have parents, many are involved in sex work.These are girls fourteen and up.These girls don't go to school, they lack fees.Some have good intentions.They raise money to go to school by selling sex.But after a while, because they are hanging out at night in bars, they lose interest in school and drop out.[163]

Human Rights Watch met Simon K., a seventeen-year-old boy who had lost both his parents to AIDS, at a youth club in Kabarole district.Simon K. was in P7 (primary school grade seven) when his parents died, but he left school to care for two brothers and three sisters."I would look around for an extra banana in a plantation and try to sell it to pay for their schooling," he said.[164]A sister and brother subsequently died, and when we met him he was caring for his two surviving sisters, aged fifteen and eighteen.With no income and little to eat, he said one of his sisters was trading sex for money and food.

She slept with an older man and was given money for it.It was last year.She was looking for a job and found work as a house girl.After she left, her boss followed her and offered her money to have sex with him. . . . He would pay her about 10,000 shillings (U.S. $5.80), I don't know exactly how much.She bought knickers and a bra with it, and with the rest she just bought something to eat.

Simon K. said he talked to his elder sister about the importance of abstinence, but to no avail."I feel she should at least try to wait for some time in the future to have sex, but not now," he said."I told her that, and she says she can't do anything about it, it's the only way she can make money.If I were able to care for her needs, I would. But there is nothing else I can do."[165]

Refugees, internally displaced persons, and children affected by conflict

Ongoing conflict in the north of Uganda between government forces and the Lord's Resistance Army (LRA) has forced an estimated 1.6 million civilians to live in internally displaced persons (IDP) camps.Commenting in November 2003 on the plight of these civilians, Jan Egeland, the U.N. Under Secretary General for Humanitarian Affairs, called the situation in the north of Uganda the biggest forgotten humanitarian emergency in the world today.[166]Children, together with adults, live in closely confined, overcrowded camps with limited access to food, water, schooling, and economic opportunity.The displacement, poverty, and lack of employment options drive women and girls to engage in paid sex with camp residents, local defense personnel, and Ugandan government soldiers.While this context makes it difficult to provide any information to those at risk of HIV, abstinence-only approaches make it particularly difficult for those affected to protect themselves from it.

According to one IDP camp leader, while there are cases of rape and sexual assault in the camps, much more common is "survival sex" or sex involving girls or young women in exchange for food or money.[167]Soldiers, who spend considerable time away from their families at isolated posts in the camps and in positions of affluence compared to the destitute people they protect, pay women and girls for sex.One NGO worker said that soldiers sometimes "will pay boys a little money, so that they will lure the women and girls to the army installations.They will later get a little money or food for their services."[168]

LRA attacks on villages and homesteads outside major towns in the north have led parents to send their children to urban centers at night to avoid abduction.Parents stay at home to guard their property while children, who are particularly targeted by the LRA for forcible recruitment into military service, are sent off near sundown and return home at sunrise.These "night commuters," as the children are commonly known, spend evenings largely unsupervised and face a high risk of sexual exploitation and assault in addition to engaging in sex with other children.Human Rights Watch has documented cases of rape of night commuters traveling to and from towns as well as in places where they sleep.[169]More common is the phenomenon of girls engaging in survival sex with civilians and soldiers and, according to one municipal official, boys and girls engaging in drinking, drugs, and sexual activities with one another.[170]

Sexual coercion and exploitation in the context of this conflict is likely responsible for higher HIV prevalence rates in northern Uganda than in the rest of the country.An antenatal testing program for mothers at LacorHospital in Gulu found that of those who volunteered to be tested, 11.9 percent tested positive for HIV in 2002 compared to a national prevalence rate of just over 6 percent.[171]In Kitgum and Pader, testing programs at three hospitals found that HIV prevalence ranged from 4.8 to 10.4 percent among pregnant women between May and December 2002.[172]

The increased risk of sexual violence, sexual exploitation, and heightened sexual activity among boys and girls require a realistic HIV prevention strategy.Preliminary results from a survey done on HIV awareness and service provisions for internally displaced persons found a large amount of early sexual activity among adolescent children; lower HIV awareness than in the rest of the country; and limited access to health services.The survey also showed that that vast majority of respondents felt that "abstinence until marriage" was an inappropriate strategy and had no relevance to their lives.[173]

Children also face a heightened risk of HIV infection in the post-conflict districts of Bundibugyo, Kasese, and Kabarole in western Uganda where the government battled the Allied Democratic Forces until 2001.Estimated HIV prevalence rates in some of these areas are as high as 20 percent, three times higher than the national average.[174]Youth leaders in Kasese told Human Rights Watch that conflict in that region had displaced tens of thousands of civilians, increased the number of orphans and street children, and contributed to lower ages of sexual debut and marriage among children.As in the north, poverty in these rural districts was exacerbated by the fighting and led more girls to engage in survival sex and prostitution.[175]The leader of a youth network in Kabarole and Bundibugyo told Human Rights Watch:

We don't think abstinence is really working in our communities.These kids are having sex.We work with children in primary five through seven who are engaging in sexual activities.We always come with the message to delay sexual debut but for most children here, this is not enough.[176]

The end of the conflict in 2001 combined with a policy of universal primary education, has resulted in an increasing number of children in western Uganda returning to finish primary school.Some of these boys and girls are in their mid to late teens and are already sexually active; some are married and have children of their own.According to youth outreach activists working in the schools, these older children were in particular need of appropriate information on how to protect themselves from HIV, not messages that promote abstinence-until-marriage.[177]

Discrimination based on sexual orientation

By definition, abstinence-until-marriage programs discriminate on the basis of sexual orientation.For young people who are lesbian, gay, bisexual, or transgender (LGBT)[178] and cannot legally marry in Uganda (as in most jurisdictions worldwide), these messages imply, wrongly, that there is no safe way for them to have sex.They deny these people information that could save their lives.They also convey a message about the intrinsic wrongfulness of homosexual conduct that reinforces existing social stigma and prejudice to potentially devastating effect.

Such stigma and prejudice in Uganda exist not only in the abstract, but are embodied in laws that criminalize same-sex sexual relations.Political and religious leaders as well as the media in Uganda help to create a climate in which the legal threat of imprisonment contributes to an environment of hatred and exclusion.[179]In 1998, for example, President Museveni told a press conference, "When I was a in America, some time ago, I saw a rally of 300,000 homosexuals.If you have a rally of 20 homosexuals here, I would disperse it."[180]His minister of gender, labour, and social development, Janet Mukwaya, later warned, "The West is bringing up homosexuality and lesbianism under a different name, called sexual orientation ... These people want their ideas to be focused in every programme, in case you come across something like sexual orientation, you have to think twice before you defend it."[181]

In a manner significant to the debates about "abstinence until marriage," these warnings repeatedly focus around fears that gay or lesbian people might actually marry.In September 1999, after (inaccurate) published reports of a wedding ceremony between two men in Uganda, President Museveni told a conference on reproductive health:"I have told the CID [Criminal Investigations Department] to look for homosexuals, lock them up and charge them."[182]Several people were jailed in the wake of this mandate.Five men and women who had formed a tiny lesbian and gay group were tortured by police. Others fled the country in fear.[183]

This environment of intimidation has a particular effect on young people.In December, 2003, an eighteen-year-old secondary school student in Nysamba was, according to press accounts, "caned several times in front of a whole school after the administration told her parents that she has been found with love letters from her fellow girls."Suspended from classes, she was later found dead in her bed shortly thereafter; while officials ruled the death a suicide, activists in Uganda suspected she may have died as a result of the beatings.[184]The press also reported that "A school in Lubaga Division punished four girls after finding out about their love affair.They were made to dig up three ant-hills plus received 30 strokes at the assembly.Another one in Makindye expelled six lesbians and two gays."[185]Fear of gay and lesbian students is actively fostered by the government.In February 2005, for instance, a Ministry of Education official warned direly in a speech about the "spread of homosexuality and lesbianism in secondary boarding schools."[186]

Despite the interlinked ignorance and fear surrounding, and silencing, homosexuality in Uganda, Human Rights Watch interviewed numerous young people in secondary schools and universities, as well as young people out of school, who identified as gay or lesbian and were sexually active.Young gay and lesbian Ugandans reported discrimination and ostracization by members of their communities, fear of seeking health services, and arrest and intimidation by law enforcement officials for suspicion of engaging in criminalized homosexual acts.The following statements, directed to Human Rights Watch researchers during the course of these interviews, all underscore the need to provide accurate prevention information on how HIV is transmitted:

The HIV/AIDS information we get says that girls under twenty are more susceptible to HIV than boys, so some guys think they can't get HIV from another boy, is this true?
At school, they talk about sex in the vagina but not anal sex, is it true you can't get HIV from anal sex?
I never knew that anal sex was a riskier form of HIV transmission than vaginal sex.
I didn't know you could get an STD from anal sex, this has never been explained to us.[187]

Former and current street children interviewed by Human Rights Watch also said that street children often had sex with other children of the same sex, or with adults who paid boys for anal intercourse.One former street boy in Kampala said he used to engage in anal sex with older boys when he lived on the street, as well as with boys his age.He said that he had no information that penetrative anal sex put him at risk of HIV because in Uganda, "this is just not talked about."[188]Another former street boy in Mbale said:

These homosexual acts occur all the time.You might have a man who wants to have sex, so he will pay a street boy a small amount of money to penetrate him.This could be anyone, a boda-boda [bicycle taxi] driver, a street cleaner, even an educated man.Some people think that by having homosexual relations, they are not going to get HIV. . . . Street children need information on the dangers of sharing razors, of not picking up from dump sites, and on using condoms correctly.They need this information to survive, not abstinence messages.[189]

Individuals involved in providing HIV/AIDS information to young people said that the political climate and criminality associated with homosexuality made it impossible to convey accurate HIV/AIDS information to gays and lesbians.This did not stop some courageous secondary school students from occasionally requesting information from them about homosexuality and HIV/AIDS, however.[190]One activist working in an academic institution told Human Rights Watch:

Men who have sex with men are erased from all HIV programs.The Uganda AIDS Commission does not want to hear about them.It is a fact that here in Uganda there is a percentage of men who are in heterosexual relationships but are having sex with men on the side.This puts women involved with them at heightened risk of contracting HIV.But nobody wants to talk about that in Uganda.[191]

Indeed, in November 2004, the Minister of Information said publicly that he had written both the Joint United Nations Programme on HIV/AIDS, UNAIDS, and the Uganda AIDS Commission to protest any "support for lesbian, gay, bisexual and transgender groups," warning: "The government position is very clear, homosexuality is illegal."[192]In response, the Uganda AIDS Commission told the press that they "had no mandate to create a policy supportive of gays when their activities were not recognized under national laws."[193]

HIV/AIDS materials in Uganda's schools, including the PIASCY materials described above, provide inadequate information on how people who engage in anal and oral sex can protect themselves from HIV, regardless of their sexual orientation.In the PIASCY upper primary teacher's book, the only reference to anal sex or homosexuality is located in the chapter entitled "Morally Unacceptable Sexual Behavior for Young Adolescents."The chapter provides a list of "immoral behavior," including sexual activity between people of the same sex.[194]The draft secondary materials for PIASCY state that HIV transmission can occur through anal sex because the lining of the anus is delicate and likely to be bruised during sex.There is no information provided, however, that condoms and lubricant when used correctly and consistently can prevent the transmission of HIV from anal sex.[195]

[151] Others have highlighted the inappropriateness of abstinence education for vulnerable communities.See Sara Rakita, "From Coffins to ABCs: AIDS Prevention in Uganda", Pambazuka News, May 13, 2004, p. 4, http://www.pambazuka.org (retrieved January 3, 2005).

[152] This is occurring even though increasing proportions of young Ugandans are postponing sex to a later age.The data in this paragraph are taken from Uganda HIV/AIDS Partnership, Uganda Ministry of Health, Uganda AIDS Commission, and MEASURE Evaluation Project, AIDS in Africa During the Nineties: Uganda: Young people, sex, and AIDS in Uganda (Chapel Hill, NC: MEASURE Evaluation, Carolina Population Center, University of North Carolina at Chapel Hill, 2004, pp. 60-62.

[153] UAC/MEASURE/MOH, AIDS in Africa During the Nineties, p. 29.

[154] Human Rights Watch interview with HIV positive woman, Kampala, November 17, 2004.

[155] Human Rights Watch interview, Kampala, November 15, 2004.

[156] Human Rights Watch interview, Kampala, November 15, 2004.

[157] Human Rights Watch interview, Kampala, November 15, 2004.

[158] Human Rights Watch interview, Kampala, November 15, 2004.

[159] UNAIDS, UNICEF, and USAID, Children on the Brink 2004, A Joint Report on New Orphan Estimates and a Framework for Action (New York: United Nations Publications, 2004), Fourth Edition, p. 30, http://www.unicef.org (retrieved January 29, 2005).The word orphan as used here described any child in Uganda who has lost one or both parents.

[160] Ibid., p. 18.

[161] Human Rights Watch interview, Kampala, November 11, 2004.

[162] Human Rights Watch interview, Mbale, November 13, 2004.

[163] Human Rights Watch interview, Mbale, November 12, 2004.

[164] Human Rights Watch interview, FortPortal, November 20, 2004.

[165] Human Rights Watch interview, Kabarole, November 20, 2004.

[166] Agence France-Press (AFP), "War in Northern Uganda World's Worst Forgotten Crisis: UN", November 11, 2003, http:// www.reliefweb.int (retrieved February 1, 2005).

[167] Human Rights Watch interview, Gulu, February 9, 2003.

[168] Human Rights Watch interview, Awer camp, Gulu, January 31, 2003.

[169] Human Rights Watch, "Abducted and Abused:Renewed Conflict in Northern Uganda," A Human Rights Watch Report, vol. 15, no. 12(A), July 2003, pp. 68-72.

[170] Human Rights Watch interview with local councilor, Gulu, February 6, 2003.

[171] UNAIDS/WHO, Epidemiological Fact Sheets: Uganda, p. 15.

[172] Information provided by the Associazione Volontari per il Servizio Internazionale (AVSI), March 6, 2003.

[173] Human Rights Watch interview, Save the Children Staff, Kampala, November 9, 2004.

[174] Joseph Mugisa, "Bundibugyo Has 20 Percent HIV/Aids Prevalence Rate," The Monitor, February 9, 2005, http://allafrica.com (retrieved February 11, 2005).

[175] Human Rights Watch interview, Kasese, November 19, 2004.

[176] Human Rights Watch interview, Kabarole, November 20, 2004.

[177] Human Rights Watch interviews, W. Uganda, November 18-20, 2004.

[178] It should be cautioned that many men who have sex with men, in Africa or elsewhere, might reject or might not even know the terms "homosexual" or "gay"; many women who have sex with women might not see themselves as comprehended under the label "lesbian."In general, Human Rights Watch describes people by the identities they ascribe to themselves; in using these terms here, we recognize that not everyone facing abuse based on sexual orientation or gender identity would recognize themselves in them.

[179] See, e.g., Daniel Elwana, "Church backs Museveni against homosexuality," Daily Nation, Nairobi, Kenya, November 14, 1999.

[180] "Museveni warns off homosexuals," The Monitor, Kampala, Uganda, July 22, 1998.

[181] Quoted in "Minister warns of homosexuals," Crusader, Kampala, Uganda, August 18, 1998.

[182]"Museveni opens a war on gay men," The Monitor, September 28, 1999. See also "Wandegeya homos marry," Sunday Vision, Kampala, Uganda, September 12, 1999; "Police probe Kampala's homosexual weddings," New Vision, Kampala, Uganda, September 13, 1999; and "Museveni, police homo probe out: `Story was made up,'" The Monitor, October 5, 1999.

[183] See Amnesty International Appeal, "Uganda: Criminalizing Homosexuality: A License to Torture," June 27, 2001; and Amnesty International, Crimes of Hate, Conspiracy of Silence: Torture and Ill-Treatment Based on Sexual Identity, AC 40/016/2001, pp. 4-6.

[184] "Schoolgirl commits suicide," The Red Pepper, December 12, 2003; e-mail communications from Ugandan activist who wished to remain anonymous, December 19, 2003.

[185] "Schoolgirl commits suicide," The Red Pepper, December 12, 2003.

[186] Samuel Wossita, "Rising gay numbers in schools worry govt," The Monitor, February 9, 2005.Almost simultaneously, the Chancellor of Makerere University, Apolo Nsibambi, "castigated" homosexuality, saying it had "rocked" the institution: "I am saddened that homosexuality has reached the university. As the chancellor, I condemn such acts." Apollo Mubiru, "MakerereUniversity homos worry Nsibambi," New Vision, February 8, 2005.

[187] Human Rights Watch interviews, secondary school students, Uganda, November 18, 2004.

[188] Human Rights Watch interview, Kampala, November 15, 2004.

[189] Human Rights Watch interview, Mbale, November 12, 2004.

[190] Human Rights Watch interview, Kampala, November 9, 2004.

[191] Human Rights Watch interview, Kampala, November 10, 2004.

[192] Izama Angelo, "Govt warns UNAIDS over gays," The Monitor, November 29, 2004.

[193] Ibid.

[194] Ministry of Education, Handbooks, p. 15.

[195] Ministry of Education, Draft Secondary Handbooks, p. 9.