Gender Norms, Gender Role Conflict/Stress and HIV Risk Behaviors Among Men in Mpumalanga, South Africa


Men’s gender role conflict and stress (GRC/S), the psychological strain they experience around fulfilling expectations of themselves as men, has been largely unexplored in HIV prevention research. We examined associations between both men’s gender norms and GRC/S and three HIV risk behaviors using data from a population-based survey of 579 18–35 year-old men in rural northeast South Africa. Prevalence of sexual partner concurrency and intimate partner violence (IPV) perpetration in the last 12 months were 38.0 and 13.4%, respectively; 19.9% abused alcohol. More inequitable gender norms and higher GRC/S were each significantly associated with an increased odds of concurrency (p = 0.01; p < 0.01, respectively), IPV perpetration (p = 0.03; p < 0.01), and alcohol abuse (p = 0.02; p < 0.001), controlling for demographic characteristics. Ancillary analyses demonstrated significant positive associations between: concurrency and the GRC/S sub-dimension subordination to women; IPV perpetration and restrictive emotionality; and alcohol abuse and success, power, competition. Programs to transform gender norms should be coupled with effective strategies to prevent and reduce men’s GRC/S.

This is a preview of subscription content, log in to check access.


  1. 1.

    Cohen SI, Burger M. Partnering: A new approach to sexual and reproductive health. New York: United nations population fund (UNFPA); 2000.

    Google Scholar 

  2. 2.

    Rivers K, Aggleton P. Men and the HIV epidemic. New York: United Nations Development Programme; 1999.

    Google Scholar 

  3. 3.

    UNAIDS. UNAIDS Report on the Global AIDS Epidemic. Geneva: UNAIDS; 2012.

    Google Scholar 

  4. 4.

    Shisana O, Rehle T, Simbayi L, Zuma K, Jooste S, Zungu N, et al. South African national HIV prevalence, incidence and behaviour survey, 2012. Cape Town: HSRC Press; 2014.

    Google Scholar 

  5. 5.

    Connell R. Gender and power: society, the person, and sexual politics. Palo Alto: Stanford Univ Press; 1987.

    Google Scholar 

  6. 6.

    Wingood GM, Camp C, Dunkle K, Cooper H, DiClemente RJ. The theory of gender and power: Constructs, variables, and implications for developing HIV interventions for women. San Fransisco: Jossey-Bas; 2009.

    Google Scholar 

  7. 7.

    Marston C, King E. Factors that shape young people’s sexual behaviour: a systematic review. The Lancet. 2006;368(9547):1581–6.

    Article  Google Scholar 

  8. 8.

    World Health Organization. Gender and HIV/AIDS. Geneva: WHO; 2003.

    Google Scholar 

  9. 9.

    UNAIDS. UNAIDS Report on the Global AIDS Epidemic 2010. Geneva: UNAIDS; 2010.

    Google Scholar 

  10. 10.

    Maman S, Campbell J, Sweat MD, Gielen AC. The intersections of HIV and violence: directions for future research and interventions. Soc Sci Med. 2000;50(4):459–78.

    Article  PubMed  CAS  Google Scholar 

  11. 11.

    Jewkes RK, Dunkle K, Nduna M, Shai N. Intimate partner violence, relationship power inequity, and incidence of HIV infection in young women in South Africa: a cohort study. The Lancet. 2010;376(9734):41–8.

    Article  Google Scholar 

  12. 12.

    Pettifor AE, Measham DM, Rees HV, Padian NS. Sexual power and HIV risk, South Africa. Emerg Infect Dis. 2004;10(11):1996–2004.

    Article  PubMed  PubMed Central  Google Scholar 

  13. 13.

    Foran HM, O’Leary KD. Alcohol and intimate partner violence: a meta-analytic review. Clin Psychol Rev. 2008;28(7):1222–34.

    Article  PubMed  Google Scholar 

  14. 14.

    Weir SS, Pailman C, Mahlalela X, Coetzee N, Meidany F, Boerma JT. From people to places: focusing AIDS prevention efforts where it matters most. AIDS. 2003;17(6):895–903.

    Article  PubMed  Google Scholar 

  15. 15.

    Kalichman SC, Simbayi LC, Kaufman M, Cain D, Jooste S. Alcohol use and sexual risks for HIV/AIDS in sub-Saharan Africa: systematic review of empirical findings. Prev Sci. 2007;8(2):141–51.

    Article  PubMed  Google Scholar 

  16. 16.

    Morojele NK, Kachieng’a MA, Mokoko E, Nkoko MA, Parry CDH, Nkowane AM, et al. Alcohol use and sexual behaviour among risky drinkers and bar and shebeen patrons in Gauteng province, South Africa. Soc Sci Med. 2006;62(1):217–27.

    Article  PubMed  Google Scholar 

  17. 17.

    Thompson EH, Pleck JH, Ferrera DL. Men and masculinities: scales for masculinity ideology and masculinity-related constructs. Sex Roles. 1992;27(11):573–607.

    Article  Google Scholar 

  18. 18.

    Pleck JH. The myth of masculinity. Cambridge: MIT Press; 1981.

    Google Scholar 

  19. 19.

    Pleck JH. The gender role strain paradigm: an update. In: Levant R, Pollack W, editors. A new psychology of men. New York: BasicBooks; 1995. p. 11–32.

    Google Scholar 

  20. 20.

    Eisler RM, Skidmore JR. Masculine gender role stress. Behav Modif. 1987;11(2):123–36.

    Article  PubMed  CAS  Google Scholar 

  21. 21.

    O’Neil JM. Men’s gender role conflict: psychological costs, consequences, and an agenda for change. Washington: American Psychological Association; 2015.

    Google Scholar 

  22. 22.

    Brooks G, Silverstein L. Understanding the dark side of masculinity: an interactive systems model. In: Levant R, Pollack W, editors. A new psychology of men. New York: BasicBooks; 1995. p. 280–333.

    Google Scholar 

  23. 23.

    Eisler RM. The relationship between masculine gender role stress and men’s health risk: the validation of a construct. In: Levant R, Pollack W, editors. A new psychology of men. New York: BasicBooks; 1995. p. 207–25.

    Google Scholar 

  24. 24.

    O’Neil JM. Summarizing 25 years of research on men’s gender role conflict using the gender role conflict scale. Counsel Psychol. 2008;36(3):358–445.

    Article  Google Scholar 

  25. 25.

    Korcuska JS, Thombs DL. Gender role conflict and sex-specific drinking norms: relationships to alcohol use in undergraduate women and men. J Coll Stud Dev. 2003;44(2):204–16.

    Article  Google Scholar 

  26. 26.

    Eisler RM, Skidmore JR, Ward CH. Masculine gender-role stress: predictor of anger, anxiety, and health-risk behaviors. J Pers Assess. 1988;52(1):133–41.

    Article  PubMed  CAS  Google Scholar 

  27. 27.

    Gallagher KE, Parrott DJ. What accounts for men’s hostile attitudes toward women? the influence of hegemonic male role norms and masculine gender role stress. Violence Against Women. 2011;17(5):568.

    Article  PubMed  PubMed Central  Google Scholar 

  28. 28.

    Jakupcak M, Lisak D, Roemer L. The role of masculine ideology and masculine gender role stress in men’s perpetration of relationship violence. Psychol Men Masc. 2002;3(2):97.

    Article  Google Scholar 

  29. 29.

    O’Neil JM, Helms BJ, Gable RK, David L, Wrightsman LS. Gender-role conflict scale: college men’s fear of femininity. Sex Roles. 1986;14(5):335–50.

    Google Scholar 

  30. 30.

    Morrell R. The times of change: men and masculinity in South Africa. In: Morrell R, editor. Changing men in southern Africa. Pietermaritzburg: University of Natal Press; 2001. p. 3–37.

    Google Scholar 

  31. 31.

    Sideris T. “You have to change and you don’t know how!”: contesting what it means to be a man in a rural area of South Africa. Afr Stud. 2004;63(1):29–49.

    Article  Google Scholar 

  32. 32.

    Hunter M. The changing political economy of sex in South Africa: the significance of unemployment and inequalities to the scale of the AIDS pandemic. Soc Sci Med. 2007;64(3):689–700.

    Article  PubMed  Google Scholar 

  33. 33.

    Shefer T, Crawford M, Strebel A, Simbayi LC, Dwadwa-Henda N, Cloete A, et al. Gender, power and resistance to change among two communities in the Western Cape, South Africa. Fem Psychol. 2008;18(2):157–82.

    Article  Google Scholar 

  34. 34.

    Harrison A, O’Sullivan LF, Hoffman S, Dolezal C, Morrell R. Gender role and relationship norms among young adults in South Africa: measuring the context of masculinity and HIV risk. J Urb Health. 2006;83(4):709–22.

    Article  Google Scholar 

  35. 35.

    Moore TM, Stuart GL, McNulty JK, Addis ME, Cordova JV, Temple JR. Domains of masculine gender role stress and intimate partner violence in a clinical sample of violent men. 2010.

  36. 36.

    Pettifor A, Lippman SA, Selin AM, Peacock D, Gottert A, Maman S, et al. A cluster randomized-controlled trial of a community mobilization intervention to change gender norms and reduce HIV risk in rural South Africa: study design and intervention. BMC public health. 2015;15(1):752.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  37. 37.

    Gómez-Olivé FX, Angotti N, Houle B, Klipstein-Grobusch K, Kabudula C, Menken J, et al. Prevalence of HIV among those 15 and older in rural South Africa. AIDS care. 2013;25(9):1122–8.

    Article  PubMed  PubMed Central  Google Scholar 

  38. 38.

    Kahn K, Collinson MA, Gómez-Olivé FX, Mokoena O, Twine R, Mee P, et al. Profile: agincourt health and socio-demographic surveillance system. Int J Epidemiol. 2012;41(4):988–1001.

    Article  PubMed  PubMed Central  Google Scholar 

  39. 39.

    Shrive FM, Stuart H, Quan H, Ghali WA. Dealing with missing data in a multi-question depression scale: a comparison of imputation methods. BMC Med Res Methodol. 2006;6(1):57.

    Article  PubMed  PubMed Central  Google Scholar 

  40. 40.

    UNAIDS Reference Group on Estimates Modelling and Projections. Working group on measuring concurrent sexual partnerships. HIV: consensus indicators are needed for concurrency. The Lancet. 2010;375(9715):621–2.

    Article  Google Scholar 

  41. 41.

    Dunkle KL, Jewkes RK, Nduna M, Levin J, Jama N, Khuzwayo N, et al. Perpetration of partner violence and HIV risk behaviour among young men in the rural Eastern Cape, South Africa. AIDS. 2006;20(16):2107.

    Article  PubMed  Google Scholar 

  42. 42.

    Centers for Disease Control and Prevention (CDC). Alcohol and public health. Accessed 28 Oct 2012.

  43. 43.

    Babor TF, Higgins-Biddle JC, Saunders JB, Monteiro MG. The alcohol use disorders identification test: Guidelines for use in primary care. 2nd ed. Geneva: World Health Organization Department of Mental Health and Substance Dependence; 2001.

    Google Scholar 

  44. 44.

    Saunders JB, Aasland OG, Babor TF, Fuente JR, Grant M. Development of the alcohol use disorders identification test (AUDIT): WHO collaborative project on early detection of persons with harmful alcohol consumption-II. Addiction. 1993;88(6):791–804.

    Article  PubMed  CAS  Google Scholar 

  45. 45.

    Bekker D, Van Velden D. Alcohol misuse in patients attending a defence force general medical clinic. South African Family Pract. 2003;45(2):10–5.

    Google Scholar 

  46. 46.

    Kalichman SC, Simbayi LC, Vermaak R, Cain D, Smith G, Mthebu J, et al. Randomized trial of a community-based alcohol-related HIV risk-reduction intervention for men and women in Cape Town South Africa. Ann Behav Med. 2008;36(3):270–9.

    Article  PubMed  Google Scholar 

  47. 47.

    Gottert A, Barrington C, Pettifor A, McNaughton-Reyes HL, Maman S, MacPhail C, et al. Measuring men’s gender norms and gender role conflict/stress in a high hiv-prevalence South African setting. AIDS Behav. 2016;20(8):1785–95.

    Article  PubMed  Google Scholar 

  48. 48.

    Pulerwitz J, Barker G. Measuring attitudes toward gender norms among young men in Brazil. Men Mascul. 2008;10(3):322.

    Article  Google Scholar 

  49. 49.

    Barker G, Contreras JM, Heilman B, Singh AK, Verma RK, Nascimento M. Evolving men: initial results from the international men and gender equality survey (IMAGES). Washington: International Center for Research on Women (ICRW) and Instituto Promundo; 2011.

    Google Scholar 

  50. 50.

    Shattuck D, Burke H, Ramirez C, Succop S, Costenbader B, Attafuah JD, et al. Using the Inequitable Gender Norms scale and associated HIV risk behaviors among men at high risk for HIV in Ghana and Tanzania. Men Mascul. 2013;16(5):540–59.

    Article  Google Scholar 

  51. 51.

    Pulerwitz J, Hughes L, Mehta M, Kidanu A, Verani F, Tewolde S. Changing gender norms and reducing intimate partner violence: results from a quasi-experimental intervention study with young men in Ethiopia. Am J Public Health. 2014;0:e1–6.

    Google Scholar 

  52. 52.

    SAS Institute. SAS/STAT 9.2 User’s Guide: The SURVEYLOGISTIC Procedure (Book Excerpt). Cary. Accessed 14 Apr 2014.

  53. 53.

    Zhao X, Lynch JG, Chen Q. Reconsidering baron and kenny: myths and truths about mediation analysis. J Consum Res. 2010;37(2):197–206.

    Article  Google Scholar 

  54. 54.

    Katz I, Low-Beer D. Why has HIV stabilized in South Africa, yet not declined further? age and sexual behavior patterns among youth. Sex Transm Dis. 2008;35(10):837.

    Article  PubMed  Google Scholar 

  55. 55.

    Pettifor AE, Rees HV, Kleinschmidt I, Steffenson AE, MacPhail C, Hlongwa-Madikizela L, et al. Young people’s sexual health in South Africa: HIV prevalence and sexual behaviors from a nationally representative household survey. AIDS. 2005;19(14):1525.

    Article  PubMed  Google Scholar 

  56. 56.

    Steffenson AE, Pettifor AE, Seage GR III, Rees HV, Cleary PD. Concurrent sexual partnerships and human immunodeficiency virus risk among South African youth. Sex Transm Dis. 2011;38(6):459.

    PubMed  PubMed Central  Google Scholar 

  57. 57.

    Parker W, Makhubele B, Ntlabati P, Connolly C. Concurrent sexual partnerships amongst young adults in South Africa. Johannesburg: CADRE; 2007.

    Google Scholar 

  58. 58.

    Christofides NJ, Jewkes RK, Dunkle KL, McCarty FA, Shai NJ, Nduna M, et al. Perpetration of physical and sexual abuse and subsequent fathering of pregnancies among a cohort of young South African men: a longitudinal study. BMC public health. 2014;14(1):947.

    Article  PubMed  PubMed Central  Google Scholar 

  59. 59.

    Peltzer K, Davids A, Njuho P. Alcohol use and problem drinking in South Africa: findings from a national population-based survey. African J psychiatr. 2011;14(1):30–7.

    Article  CAS  Google Scholar 

  60. 60.

    Barker G, Ricardo C. Young men and the construction of masculinity in sub-Saharan Africa: Implications for HIV/AIDS, conflict, and violence. Washington: World Bank; 2005.

    Google Scholar 

  61. 61.

    Hargreaves JR, Bonell CP, Morison LA, Kim JC, Phetla G, Porter JDH, et al. Explaining continued high HIV prevalence in South Africa: socioeconomic factors, HIV incidence and sexual behaviour change among a rural cohort, 2001-2004. AIDS. 2007;21:S39.

    Article  PubMed  Google Scholar 

  62. 62.

    Kalichman S, Simbayi L, Cain D, Cherry C, Henda N, Cloete A. Sexual assault, sexual risks and gender attitudes in a community sample of South African men. AIDS care. 2007;19(1):20–7.

    Article  PubMed  CAS  Google Scholar 

  63. 63.

    Glanz K, Schwartz MD. Stress, coping, and health behavior. health behavior and health education: theory, research, and practice. New York: Wiley; 2008.

    Google Scholar 

  64. 64.

    SANAC . HIV and AIDS and STI Strategic Plan for South Africa, 2012–2016. South African National AIDS Council (SANAC), 2012.

  65. 65.

    UNAIDS, WHO, Report on the global AIDS epidemic. Chapter 3: Addressing societal causes of HIV risk and vulnerability. Geneva: UNAIDS; 2008.

    Google Scholar 

  66. 66.

    World Health Organization. Engaging men and boys in changing gender-based inequity in health: evidence from programme interventions. Geneva: World Health Organization; 2007. p. 9241595493.

    Google Scholar 

  67. 67.

    Dworkin SL, Dunbar MS, Krishnan S, Hatcher AM, Sawires S. Uncovering tensions and capitalizing on synergies in HIV/AIDS and antiviolence programs. Am J Public Health. 2011;101(6):995–1003.

    Article  PubMed  PubMed Central  Google Scholar 

  68. 68.

    Dworkin SL, Treves-Kagan S, Lippman SA. Gender-transformative interventions to reduce HIV risks and violence with heterosexually-active men: a review of the global evidence. AIDS Behav. 2013;17(9):2845–63.

    Article  PubMed  Google Scholar 

  69. 69.

    Sonke Gender Justice Network. One Man Can. 2014.

  70. 70.

    Jewkes R, Nduna M, Levin J, Jama N, Dunkle K, Khuzwayo N, et al. A cluster randomized-controlled trial to determine the effectiveness of stepping stones in preventing HIV infections and promoting safer sexual behaviour amongst youth in the rural Eastern Cape, South Africa: trial design, methods and baseline findings. Tropical Med Int Health. 2006;11(1):3–16.

    Article  CAS  Google Scholar 

  71. 71.

    Peacock D, Levack A. The men as partners program in South Africa: reaching men to end gender-based violence and promote sexual and reproductive health. Int J Men’s Health. 2004;3(3):173–88.

    Article  Google Scholar 

  72. 72.

    Pulerwitz J, Michaelis A, Verma R, Weiss E. Addressing gender dynamics and engaging men in HIV programs: lessons learned from Horizons research. Public Health Rep. 2010;125(2):282.

    Article  PubMed  PubMed Central  Google Scholar 

  73. 73.

    Jewkes R, Nduna M, Levin J, Jama N, Dunkle K, Puren A, et al. Impact of stepping stones on incidence of HIV and HSV-2 and sexual behaviour in rural South Africa: cluster randomised controlled trial. BMJ. 2008;337:a506.

    Article  PubMed  PubMed Central  Google Scholar 

  74. 74.

    Dunkle KL, Jewkes R. Effective HIV prevention requires gender-transformative work with men. Sex Transm Infect. 2007;83(3):173–4.

    Article  PubMed  PubMed Central  Google Scholar 

  75. 75.

    Podsakoff PM, MacKenzie SB, Lee J-Y, Podsakoff NP. Common method biases in behavioral research: a critical review of the literature and recommended remedies. J Appl Psychol. 2003;88(5):879.

    Article  PubMed  Google Scholar 

Download references


We would like to thank the study participants for sharing their time and perspectives with us. We would also like to thank the staff of the MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt) for their support of the parent study, including data collection. Amada Selin, Tamu Daniel, Sheree Schwartz and Rushina Cholera also assisted with study coordination and data collection. This study was supported by a Ruth L. Kirschstein National Research Service Institutional STD/HIV Pre-Doctoral Training Award (National Institutes of Health DHHS/NIH/NIAID: 5 T32 AI 07001-35) through the University of North Carolina at Chapel Hill Institute for Global Health and Infectious Diseases. The National Institute of Mental Health provided funding for the parent study for this research (1RO1MH087118, A. Pettifor, PI; 1R21MH090887, S. Lippman, PI).

Author information



Corresponding author

Correspondence to Ann Gottert.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Gottert, A., Barrington, C., McNaughton-Reyes, H.L. et al. Gender Norms, Gender Role Conflict/Stress and HIV Risk Behaviors Among Men in Mpumalanga, South Africa. AIDS Behav 22, 1858–1869 (2018).

Download citation


  • Gender role
  • HIV
  • Sexual behavior
  • Violence
  • Alcohol
  • South Africa