- Basic Sexological Premises 228
- Religious, Ethnic, and Gender Factors Affecting Sexuality 230
- Knowledge and Education about Sexuality 231
- Autoerotic Behaviors and Patterns 231
- Interpersonal Heterosexual Behaviors 231
- Homoerotic, Homosexual, and Bisexual Behaviors 232
- Gender Diversity and Transgender Issues 235
- Significant Unconventional Sexual Behaviors 235
- Contraception, Abortion, and Population Planning 236
- Sexually Transmitted Diseases and HIV/AIDS 238
- Sexual Dysfunctions, Counseling, and Therapies 239
- Sex Research and Advanced Professional Education 239
- References and Suggested Readings 239
*A Note for Researchers: The numbers included in the section titles in the Contents above refer to the page numbers in the print edition of the CCIES. For the convenience of researchers, an Adobe Acrobat (PDF) file of this chapter is available for download above (click the PDF icon), which reflects the actual pagination of the book. This will allow scholarly writers to cite actual page numbers in the printed book for quoted material, as well as its availability on the Web and the URL if desired. See also How to Use This Encyclopedia.
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[Note from the CCIES Website Editor: Please send any additions, corrections, or updated information to: Raymond J. Noonan, Ph.D.]
Demographics and a Brief Historical Perspective
This Central American country lies between Nicaragua and the Lake of Nicaragua to the north and Panama to the south. Its area of 19,730 square miles (51,100 km2) slightly exceeds that of the combined states of Vermont and New Hampshire in the U.S. Its western border is the North Pacific Ocean with a narrow Pacific coastal region. About 300 miles (480 km) offshore, the 10-square-mile (26-km2) Cocos Island is under Costa Rican sovereignty. The Caribbean Sea marks Costa Rica’s eastern border.
Costa Rica’s climate is tropical and subtropical, with a dry season from December to April and a rainy season from May to November. A cooler climate prevails in the highlands. Costa Rica’s terrain consists of narrow coastal plains separated by rugged mountains. The country has four volcanoes, two of them active, which rise near the capital of San José in the center of the country. One of the volcanoes, Irazu, had a destructive eruption in 1963-1965.
In July 2002, Costa Rica had an estimated population of 4.008 million (1,969,680 females and 2,038,585 males). (All data are from The World Factbook 2002 (CIA 2002) unless otherwise stated.)
Age Distribution and Sex Ratios: 0-14 years: 30.8% with 1.05 male(s) per female (sex ratio); 15-64 years: 63.9% with 1.02 male(s) per female; 65 years and over: 5.3% with 0.87 male(s) per female; Total population sex ratio: 1.02 male(s) to 1 female
Life Expectancy at Birth: Total Population: 77.7 years; male: 75.6 years; female: 79.9 years
Urban/Rural Distribution: 50% to 50%
Ethnic Distribution: white (including mestizo): 96.5%; black: 1.9%; Amerindian: 1.3%; Chinese: 0.2%
Religious Distribution: Roman Catholic: 76.3%, Evangelical: 13.7%; Jehovah’s Witnesses 1.3%, other: 4.8%; none: 3.2%
Birth Rate: 21.4 births per 1,000 population
Death Rate: 4.1 per 1,000 population
Infant Mortality Rate: 10.8 deaths per 1,000 live births
Net Migration Rate: –0.52 migrant(s) per 1,000 population
Total Fertility Rate: 2.42 children born per woman
Population Growth Rate: 1.61%
HIV/AIDS (1999 est.): Adult prevalence: 0.54%; Persons living with HIV/AIDS: 12,000; Deaths: 750. (For additional details from www.UNAIDS.org, see end of Section 10B.)
Literacy Rate (defined as those age 15 and over who can read and write): 95.5% (education is free and compulsory from age 6 to 15)
Per Capita Gross Domestic Product (purchasing power parity): $8,500 (2001 est.); Inflation: 12.1% (2002 est.); Unemployment: 5.2% (2002 est.); Living below the poverty line: 20.6% (1999 est.)
B. A Brief Historical Perspective
Costa Rica was inhabited by an estimated 25,000 Guaymi Indians when Columbus explored it in 1502. Few of the indigenous people survived the Spanish conquest, which began in 1563. The region grew slowly and was administered as a Spanish province. Costa Rica achieved independence in 1821, but was absorbed for two years by Agustín de Iturbide in his Mexican empire. Costa Rica seceded from the Central American Federation in 1838 and became a republic in 1848. Except for the military dictatorship of Tomás Guardia from 1870 to 1882, Costa Rica has enjoyed one of the most democratic governments in Latin America. Since the civil war of 1948 and 1949, there has been little social conflict and free political institutions have been preserved. The presidency of Rodrígo Carazo Odio (1978-1986) was marked by a disastrous decline in the economy. Oscar Arias Sanchez, who became president in 1986, prevented the neighboring Nicaraguan Contra rebels from using Costa Rican territory as a safe haven, and played a central role in negotiating settlements in both the Nicaraguan and the Salvadoran civil wars. He was awarded the Nobel Peace Prize in 1987. During 1993, there was an unusual wave of kidnappings and hostage-taking, some of it related to the international cocaine trade. José Maria Figueres Olsen of the National Liberation Party became president in 1994. He favored greater government intervention in the economy and other measures that the International Monetary Fund was unhappy about. As a result, the World Bank withheld $100 million of financing. In 1998, Miguel Angel Rodriguez of the Social Christian Unity Party became president. A border dispute with Nicaragua has threatened Costa Rica’s tourism industry in the ecologically rich San Juan River area.
Costa Rica has achieved a relatively high standard of living in comparison to the rest of the Central American countries. Its economy is based on tourism, foreign investment, and agriculture. The country is noted for its political stability, and for its relative investment in health and in education and not in maintaining an army. However, as studies show, during the last 20 years, there has developed a large gap in income between one sector of the population who live at first-world standards (levels of consumption, private bilingual education, travel, etc), and other sectors with diminishing capacities to purchase even the bare necessities.
A. Character of Gender Roles
The situation of women’s sexualities in this small country reflects some unique and particular traits in the national gender social arrangements, and it also reflects larger universal trends, which affect women individually and collectively. Unlike the rest of the Central American countries that have suffered revolutions, invasions, genocide, civil war, and natural disasters, this country has had the freedom and time to develop a women’s movement, with its accompanying gender studies and theories, which in varied ways have been put into practice in different areas of the law, such as women’s rights, women’s studies at a graduate level, and so on. This concerted effort has had positive results. Domestic and sexual violence in all its multifaceted aspects has not only been made visible, but is being fought through a national program of prevention of violence. As a result of many years of work with lawyers, judges, and doctors, nowadays, men who rape or engage in sex with their own children or other children are sent to jail for 12 years or more. In March of 2003, an Evangelical pastor was sentenced to 61 years for repeatedly abusing a 12-year-old girl. Likewise, women’s sexual and reproductive health and rights, after the world congresses in Cairo and Beijing, are on the agendas of some women’s organizations and some state institutions, with projects mainly directed at young adolescent women. Progress is being made, with the creation of a National Committee on Reproductive and Sexual Health and Rights and with changes in the attention women receive in health centers, to name just a few. This is not to say that there has not been opposition, mainly from doctors, lawyers, and the Church.
These significant steps, however, must be understood in the larger context. This small country, with a “democratic” and non-military tradition, during the 1980s and early 1990s served, on the one hand, as a springboard for U.S. activities (cultural and political) throughout Central America and, on the other, as an exemplary exception, which had to be kept free of the region’s endemic contamination—political upheaval. The “Americanization,” or more specifically, the “Miamification,” with American influences arriving via the Cuban community in Miami, Florida, has seen the proliferation of U.S. education, products of all types, movies, cable television, and magazines, as well as U.S.-style gyms and diet or aesthetic centers, shopping malls, pornography, sex shops, and cosmetic surgery.
The body culture of this society has been affected by globalization and has undergone drastic changes in the last 20 years. The increasing secularization, where the control of women by fathers and husbands, as well as by social institutions, like the Church, has changed. The control of women’s virginity, marriageability, and reproduction has loosened and has been supplanted by an emphasis on women’s control of their bodies—their appearance and shape. Anorexia and bulimia are problems particularly among middle-class female adolescents. The fast turnover of women’s images, through ads, pornography, and movies, emphasizing parts of the nearly always-white bodies, has also affected men’s attitudes towards women and towards their own physicality and sexuality, and how they think about women.
The globalization process has deepened the differences between the rich and the poor. Since 1979, half a million Nicaraguans, 70% female, have fled the hunger and unemployment in their country, and have made Costa Rica their home. The thriving tourist industry, Costa Rica’s principal income, has stimulated the prostitution and pornography industries; children are for sale to older men. At the same time, Costa Rica has become an international center for cosmetic surgery. White and slim are the models that surround us in the ads, medical pamphlets, and television. Many women and some men come to Costa Rica, principally from the United States and some from Europe, to undergo cosmetic surgery, because it is cheaper than at home.
As for sex, it would be erroneous to talk about a sexual culture in terms of “Costa Ricans do this or that . . .” as a national characteristic, or even to say that some women are liberated, others not. What becomes clear after working with hundreds of women from different social backgrounds are the common elements, such as ignorance, silence, and helplessness that color their experience, regardless of social class or religion. It is sad, though familiar, to hear women admit to faking orgasms; but it is painful to hear them admit to not knowing what an orgasm is, and even worse, to not knowing what a clitoris is—or to hear peasant women say, “My husband uses me twice or three times a week.”
We could attribute this to poverty and a Third-World mentality, but this is a too-narrow perspective. Most women are ignorant about sex and their sexuality, and in particular, about their bodies, in all cultures that I know. Here, it is relevant to understand that we are talking about two very distinct but articulated worlds that exist in most nations: First and Third worlds, separated not by North/South, developed/undeveloped—but by gender constructions predicated on class differences, on maintaining power inequalities between women and men, and on the perpetuation of the “undevelopment” of all women. Ignorance about the body and sex, invisibility of the diversity of preferences and lifestyles, violence in its multifaceted forms, poverty, pornography, and so on, all contribute to maintaining women in an undeveloped status and mentality.
The situation of men’s sexuality, compared with women’s, reflects some unique and particular traits, as well as larger, universal trends. In the last eight years, research on the behavior of specific groups of men has initiated a process of deconstruction of the mythical, monolithic, universal male. Latin American masculinity has been conflated with machismo, something that is seen as particular to Latin men, hence the idea of the Latin lover, but also the idea that all Latin American men are machistas, and what is more, much more machistas than, let’s say, North American or British men.
When we step out of the realm of stereotype and begin to decipher and interpret reality, in this case, the reality of how men live their sexuality in Costa Rica, we begin to detect a reality colored by ignorance, silence, and compulsion. Compulsion here denotes obligation, a performance pressure. Men have the obligation to demonstrate their “masculinity” at all times, at work, in public, when courting, in bed. They have learned to push, cajole, and manipulate in order to get what they want sexually. This, in feminist terms, is one of the components of sexism, another word for machismo. Machismo, as defined by an 18-year-old Costa Rican youth is “men’s fear that women will surpass them.” As defined by a university professor, it is “a complex of strategies aimed at keeping male control of power resources regarding women; it is a set of beliefs and practices regarding men’s superiority over women.”
The cultural particularities of this type of sexism has different manifestations and clear guiding principles. The following are phrases from men of varying social backgrounds in a men’s support group: men are unfaithful by nature; men are polygamous by nature; it is genetic; men have the right to every female; the penis has a life and personality of its own; men have to show women about sexuality; it is a man’s job to please women sexually; and so on. Some married men have lovers. Some men have more than one, maybe two, three, or even four lovers at a time. These relationships vary in intensity and significance. Some men have additional families.
The male’s need to demonstrate his manhood is done through the constant acting out of an active sexuality, where he proves that “it can work” and that he “does it very well.” Women, on the other hand, according to these men, should be passive and ignorant. The reduction of male sexuality to a functioning virile organ precludes pleasure and sensuality and other erotic stimulants. Sex is about penetration, and all rituals—dining out, wine, and candles—that are a buildup for intercourse. If it does not take place, men are disappointed and feel that they have failed. When asked when they felt they had become men, many answered, when they first “penetrated” a woman. Only a few years ago, it was a custom for young men to be taken by their fathers to visit prostitutes in order to have their first experience of intercourse, and consequently, become a man.
It is not surprising that men live their sexuality with stress, pain, and anguish. Male sexuality, like that of women, is predicated on ignorance. Men are ignorant about their bodies and their genitals, and needless to say, they are ignorant about women’s bodies and genitals. At the same time, they feel threatened and “feminized” by ideas that point to erotic pleasure, to communication and sensuality. And they also feel threatened when asked to take responsibility for their sexuality, when asked to use the condom, for example.
In Madrigal’s 1998 study of sexual behavior of truck and trailer drivers in Central America—Guatemala, El Salvador, Honduras, Nicaragua, Costa Rica, and Panama—we find a group of men who travel from country to country, are absent from their homes and families for long periods of time, and who habitually have sexual relations with sex workers—sometimes with transvestites or with homosexuals—in the border towns of all the countries. Their truck, particularly the cabin, becomes a second home, where they keep their things, sleep, and have sexual relations. A second family is formed by becoming friends with the prostitutes. Often sex workers are picked up at one border and dropped off at the next, where they, in turn, pick up another trailer driver. Commercial sex is mobile, and they compare themselves to sailors: “To be a trailer driver is like being a sailor: The sailor has a love in every port, the trailer driver in each customs town.” Infidelity by their wives or partners is not tolerated, but they justify their own infidelity by saying, “it is men’s right,” “men never stop having sexual relations,” “it is natural in men,” or “it is impossible to hold on for 15 days,” and so on.
But sexual pleasure is not a bilateral event. A 1992 study found that two out of five women had never experienced orgasm. Foreplay is rare; sex is equated with intercourse, and this, says sexologist Mauro Fernandez, seldom lasts more than two or three minutes. Premature ejaculation is a problem for 70% of sexually active Costa Rican men.
A 1992 survey by La Republica newspaper revealed that 87% of married and cohabiting women in a sample survey said they had been unfaithful before the age of 45. Two out of every five wives or widows over age 60 reported having had extramarital affairs at some time in the past. Most of these women, however, reported only a few instances of extramarital sex, which usually occurred, they said, because they did not feel loved or valued.
Until the late 1960s, the demands of farm life encouraged Costa Ricans to have large families. After living conditions improved and government health programs provided prenatal care, the birthrate reached a world high in 1960, 55.4 births per 1,000 population. Then, a phenomenon occurred that intrigued population experts: the birthrate dropped to 29.5 per 1,000 in 1975. Costa Rica is the only Latin American country—and one of very few in the world—in which the birthrate has fallen so sharply. The 25% drop between 1960 and 1968 occurred despite Church and state opposition to birth control. Since the 1970s, however, the government has promoted family planning.
The “family” in Costa Rica is a very important institution, and it is the center of people’s lives. They have been close exclusive units with extended close kinship networks, where relatives gather on important events. Nowadays, although many people strive to create secure families, there have been many social changes that have affected and changed the traditional family unit. Families are smaller, many women work outside of the home, many children have migrated to other countries, and there are more divorces and many single-parent households, particularly single mothers. In an effort to recognize the reality of women’s situation, in the process of the feminization of poverty, many feminist scholars began to change the concept to “families,” as a way of deconstructing the monolithic, naturalizing, all-encompassing concept of nuclear families—parents and their unmarried children— that made up 53% of all Costa Rican households in 1996. In four out of five of these families, the parents were married; the rest cohabited in unión libre, “free union,” a legally recognized relationship. Female-headed households, mostly single mothers and their unmarried children—and often their daughter’s children as well—accounted for 20% of all households. Couples without children and one-person households, mostly among the elderly, accounted for about 12%. The remaining 15% were extended-family households—couples living with at least one of their children and one or more grandchildren or other relatives. Many free unions are as stable as marriages; they are sometimes called matrimonies de hecho—de facto marriages. Recognizing this fact, a 1995 law gives cohabiters exactly the same rights and obligations as married couples, including “divorce” after three years with accompanying provisions for child support and division of property.
Vestiges of older gender roles are reflected in the many popular songs that depict women as willing to sacrifice everything for a man’s love. But women are increasingly challenging double standards, as did the Costa Rican suffragists before 1949. A revived women’s movement has flourished since the 1980s, when poverty, which especially affects women and children, began to increase. By 1993, some 40 well-established feminist groups existed, with goals ranging from bank credit for women to the eradication of domestic violence and gender stereotypes in schooling—the Law Against Domestic Violence was established in 1996. Of over 180 delegations to the Fifth International Women’s Conference in Beijing in 1995, Costa Rica’s was one of only ten that approved the proposed platform for action without reservations.
Males increasingly have had to accept changes in gender roles. Many more fathers play with their children. Government now expresses support for gender equality. The 1990 Law for Promotion of the Social Equality of Women applies to many areas of life, ranging from political party caucuses to images used in advertisements. Violations of antidiscrimination laws are frequent. In 2002, the Law of Paternity was created to make men economically responsible for the children they engender; their DNA is tested when they contest or deny paternity.
A. Source and Character of Religious Values
Costa Rica is one of the few nations in the world with an official religion: Roman Catholicism. Thus, the public education system includes religious instruction for all students. All Costa Ricans contribute through their taxes to the salaries of the clergymen. The Church is represented at all official government functions and there is no aspect of national life that is not influenced by it. Most Costa Ricans are baptized, married, and blessed before interment by Catholic priests. Crucifixes and saints’ pictures are prominent in homes, schools, government offices, and motor vehicles. Shrines to the Virgin are common in public buildings, parks, and front yards. All this expresses, if not a religious practice, definitely, a deeply imbedded cultural practice.
Some four out of five Costa Ricans say they are Catholic. But their Catholicism has long been blended with indigenous, occult, and secular beliefs and practices. The Catholic majority is still reluctant to accept many Church doctrines. Many do not believe in an afterlife and have no qualms about practicing contraception or consulting witches and fortunetellers. As school enrollment has grown, both the number and the percentage of children who receive the two weekly catechism lessons has also increased. Confirmation takes place around age 15. Many Costa Ricans consider classes in Catholic doctrine essential to the formation of the “Costa Rican character.”
The 1949 Constitution retained the 1871 constitutional provision that “neither clergy nor laymen may make political propaganda of any sort by invoking religious motives or by taking advantage of religious belief.” But clergy can exert political influence in other ways. Padre Benjamin Nuñez was active in the PLN (Partido Liberación Nacional) until his death in 1994. He had also been “married” two times and had children. However, the Church is very actively involved in the gender politics of the country, a politics that goes beyond political parties. One writer charges that the Catholic Church has become “a State within a State,” the fourth power of the government. He regards its official status as a violation of the liberty of conscience supposedly guaranteed by the Constitution. Thanks to government policies since the 1940s and to the clergy’s “constant reprimands, admonitions and social pressures on the members of the three powers of the Republic,” its power is evident in all aspects of public life.
The Church has the power of veto in many public and private decisions. When a group of lesbians tried to organize an international conference in the country in 1990, the Church reprimanded the government for having given permission to the organizers, and public opinion was stirred up against the event. The minister of justice declared that foreign participants would be prohibited from entering the country, adding that lesbians are easy to recognize. The jokes in the press said that he had created a ‘lesbometer.’
To date, the Costa Rican government has been unable to teach sex education in high schools. The Catholic Church has rejected the instruction manuals prepared for this purpose by the Ministry of Education, arguing that the texts contained “moral irregularities.” The Church demanded changes be made, insisting on their own blueprint of sex education, which is opposed to premarital sex, non-reproductive sexual practices, abortions, most family planning methods including the condom, and respect for sexual diversity. It also includes an open and hostile rejection of feminism and gender theories.
In 1998, during the administration of President Miguel Angel Rodríguez, a project named Amor Joven (Young Love) was created by the INAMU (National Institute of Women’s Affairs) and by the First Lady, Lorena Clare. This project followed the guidelines of the Cairo+5 proposals, and was aimed at working women and empowering adolescent mothers by preparing them from a human rights and gender perspective for a sexuality based on knowledge and negotiation. The Church hierarchies denounced the project, and for many months all priests were instructed to denounce and criticize it from their pulpits. The Church said that the project was immoral and that it would induce the youngsters to promiscuous behavior. As the Church was on the Board of this government project, they wielded considerable political clout. If the government insisted in executing the project as it stood, the Church would persuade the public to go against the government. The Church changed the project by eliminating words, such as, gender, sex, vagina, penis, self-determination, and autonomy. The project died from asphyxia.
In 1998, a group of women’s NGOs, together with the Ombudswoman and the then-Vice Minister of Health, Dr. Xenia Carvajal, organized and managed to put enough pressure on the Doctor’s Association of Costa Rica, which until then, made all decisions regarding sterilizations, abortions, and other sexual and reproductive matters. The demand was that these decisions should not be made by an exclusive group, but by an interdisciplinary and interinstitutional group. A committee was created, which includes members of NGOs, universities, and government institutions, as well as international organizations in the country. As a result, a decree was promulgated that declared it the right of every woman to be sterilized on demand. The Church’s reaction was extreme, as was that of a certain conservative public, and it retaliated by going along with the decree on the condition that a Day of the Unborn be created in the country—July 27 is that day. All this reinforces the pro-life movement and Opus Dei, the extreme conservative wing of the Catholic Church.
How Catholicism is practiced varies greatly among the population. Some speak of having “blind faith”; young urbanites deny any religious belief. Most people fall somewhere in between, practicing their religion “their way,” following a marked cultural pattern of individualism, a highly personal, syncretic approach to religion. Many Catholics question the authority of the clergy, particularly after the snowball effect regarding the sexual abuse of young boys and girls by priests, which became public and visible in the United States, and which also broke the silence of abuse in this culture. Many Costa Ricans insist on freedom to decide for themselves how many children they should have: “If the padre wants me to have more, let him feed them.” A young, newly married campesino (farmer) told us, “The pope preaches that birth control is a sin, but I think he’s mistaken in that,” (Biesanz).
Likewise, many priests are tired of hearing bishops urge moral reform and charity, as well as more preaching of the gospels, as the only solutions to poverty and other social ills. Many of these priests are active in community projects.
Many Catholics have become disillusioned with their Church and have sought alternative practices, mainly in Protestant Evangelical churches, which abound in the country. This is a worldwide phenomenon, which has forced the Vatican to renovate their zeal and direct their attention at specific topics, such as, sexuality, birth control, abortion, feminism and gender theories, and homosexuality—all the crucial points fought for by feminists in the Cairo and Beijing Conferences. At the same time, Church authorities have directed their attention to the governments of Catholic countries, and put pressure directly there.
It is interesting and fearful to see how this works in this culture. Before the Cairo+5 meeting in The Hague in 1999, a Vatican official made personal calls to different government ministers, insisting that Costa Rica adhere to the Vatican guideline in the official presentation in The Hague. To this date, this direct pressure from the Vatican has not produced anyone with the strength to tell the Church to keep out of its business. Fear of losing power and voters has made some Protestant presidents convert to Catholicism. One Vatican tactic was to invade the Beijing+5 conference in New York in 2000, with barefooted monks in subtle colored habits, which forced many of the participants to meet clandestinely. Another Vatican tactic is to invite all the presidents in the region, including some ministers, congresspersons, and their wives, to an audience with the Pope himself. The spell of obedience is cast, the conservative wing of the Church is vindicated, and the work towards change becomes even harder.
Costa Rican Indians have never been a homogeneous group. The 400,000 or so aborigines living in the area in 1502 belonged to many societies, distinct both politically and culturally. Today’s 30,000 Indians—about 1% of Costa Rica’s population—include members of the Bribri, Huetar, and Talamanca cultures. Almost all live as subsistence farmers in 75 communities within the 22 officially designated Indian reserves, which compose about 6% of the national territory.
The fertility of Indian women is higher than the rest of the female population, with an average of 4.1 children, whereas, other women in the country have an average of 2.7. The organization by age and sex shows that this population is younger than the rest of the country. The percentage of people younger than 15 years of age is 46%, and those over 65 years only 3.7%, in contrast to the rest of the country which is at 5.6%. Illiteracy is high—the average attendance at school in the reserves is 3.6 years; in some areas, it is less than one year. Three quarters of the indigenous peoples live in dispersed rural reserves. There are no investigations about the sexuality of the Indian or the black communities.
As noted earlier, there is no sex education in Costa Rica, and there is no national policy for sexual education. The Ministry of Education is supposed to be in charge of sexual education, and although they have elaborated a conceptual document of what sexual education should contain, it has not materialized. The Church is the biggest opposition to sexual education, insisting that it should be the task of parents to educate, and to promote abstinence. The Ministry of Health also has a document about sexual education; the Faculty of Education in the University of Education has an Office of Sexual Education and a full-time professor in charge. All this with no evidence of sexual education.
No information is available.
A/B. Adolescents and Adults
Male and Female Sexuality
The subject of human sexuality has only become evident in Costa Rica during the last ten years. This is in part because of the introduction of sexology by sexologists, to the high incidence of teen pregnancies, to the HIV/AIDs epidemic, to the introduction of gender theories and studies, and most of all, to the process of globalization and the influence of North American and European immigrants. Sexuality has been analyzed from the standpoint of the problematic consequences it has on women, and, mainly in women’s magazines and journals, on how to achieve more pleasure and more orgasms. Heterosexuality as a patriarchal institution has come under scrutiny in the Woman’s Studies master’s program in the University of Costa Rica, and in some NGOs.
On the other hand, government projects directed at poor young women center their discourses on the sexuality of young adolescent women and on the prevention of unwanted pregnancies. Meanwhile, popular magazines dealing with sexual enhancement concentrate on male coital pleasure and ignore information that could make women the protagonists of their own sexuality. Sexual pleasure as a right is not the objective. In the case of poor women, the problem of unwanted pregnancy is frequently seen as the woman’s problem only, and the men responsible disappear and are invisibilized. Women’s sexuality is represented as being the cause of the problem.
Negotiating Safe and/or Pleasurable Sex
In one study of sexual behavior and expectations in relation to pregnancy prevention and family planning, Schifter and Madrigal (1996) compared a poor coastal community characterized by poverty, unemployment, and female-headed families with urban, middle-class, young women and men from stable two-parent homes.
In the poor coastal community studies by Schifter and Madrigal, the young daughters learn about sexuality from romantic or religious sources—pure and unblemished love, fidelity in marriage, and virginity before marriage. The sons, also influenced by these discourses, learn from gender discourses and from erotic literature, and concentrate more on pleasure. However, both sexes aspire to happiness in marriage and to saving their virginity for marriage. The young women clearly expressed themselves in terms of getting a man, of marrying, and of having a “normal” family, the romantic heterosexual script predominating. At the same time, in the face of a harsh reality, their bodies are the only means for obtaining recognition and pleasure. It is not surprising, say the authors, that these youngsters experiment with varied sexual practices from an early age, such as bestiality, group sex, sadomasochism, anal, and oral sex.
Despite defending the religious conceptions about sexuality, the consequences of their lack of alternatives are the contradictions between what they say and what they practice. Poverty makes the romantic ideal of marriage a material impossibility, and not having access to other status symbols, like professions or political power, they are limited to concentrating everything on their bodies and not in other aspects of life. The young women have a reputation to protect; the men have to prove their manhood and insist that their “girlfriends” prove their love by giving in to their sexual demands. “When one sins for love, everything can be forgiven,” many of the young women alleged; in this way, love is a cleanser of sins, and a short-lived palliative. It is only when the men fall in love that they adopt a “romantic” and protective stance to their loved one, and begin to make a clear distinction between her and “other” women, and for a brief period, their idea about men’s superiority diminishes.
In this community, gender roles are much more traditional, much more dichotomous than the youth community described above. Gender in the poor coastal community is determined by the physical activity that each person carries out. According to their own definition, everyone who is “active” and “aggressive” is a man. And all those who are “passive” and “dominated” are women. It is in this context that the phenomenon of the “cachero” and its particular symbolism emerges. In this community, similar to the marginal cultures of prisons, or in “transvesti” prostitution, sexuality is not defined by the sexual object, but by who dominates whom. In the case of the cacheros, we have heterosexual men, generally married and with children, who have sex with passive homosexuals. Nobody makes fun of these men, because they know only too well that these are very “masculine” men capable of physical aggression. For this reason, to be a cachero does not carry a stigma. On the contrary, a cachero is considered to be a macho, so manly in fact that he “screws” both men and women.
The other community in this study is urban and middle class, and the young women and men originate from stable two-parent homes. This group was much more informed about pregnancy, STD prevention, and AIDS. They are also very clear about the importance of both sons and daughters studying for a career, and for waiting to marry until they are established. In their case, the religious mandates to wait to have sex until married, and the prohibition of the use of contraceptives, becomes obsolete when faced with long university studies. The control of women by men, however, is done under more symbolic and mental forms. Sexuality is a restricted terrain for women, where they are prohibited from acquiring knowledge and experience, unless it is with their boyfriends. Sexual relations before marriage are permitted as long as it is under the control of a man who is their “protector.” Flexibility in relation to women’s virginity is contrasted with the high price that women pay when they become single mothers or are not able to marry. Single women are relegated to poverty or to taking care of their families, that is, if these forgive them their error. Working in workshops with women from this background, I have found that, despite the clarity about becoming economically solvent, many of these women live out a body culture marked by self-rejection and obsession with their size and form. Many diet constantly, some begin to have cosmetic surgery from a very early age, and some prefer to have cesarean births in order not to lose their shape. The sexuality of the women from these two communities is influenced by distinct body cultures, in the sense that there are different attitudes and expectations, and vastly different experiences. Nonetheless, the inability to negotiate safe and/or pleasurable sex marks both groups.
Balancing Women’s Conflicting Values
In another study of adolescent women in a marginal urban community with a high incidence of early pregnancy, illiteracy, and underemployment (Preinfalk Fernandez 1988), it became clear that the young women were pressured into having sexual intercourse by the men, and also by their girlfriends. At the same time, these young women are aware that their value resides in being virgins, but also in having a man and in keeping him. The young men’s preoccupation is in “scoring” the highest number of females, and sex is practiced with no protection of any kind. Unwanted pregnancies are the result, and sometimes the man stays for a while in a stable union. Once women have lost their virginity, they develop many different strategies to negotiate their “desirability,” for an experienced woman is seen as a slut. This is also an element that exists among the middle class. We could attribute these ideas about the “good” and “bad” women to the Catholic culture, and in many ways it has a profound influence on the collective mentality, but there are many other influences that persistently devalue and debase women and their bodies. Women are depicted as objects in pornography, advertisements, television, and every medium imaginable. And this is accompanied by the increase in violence against women and in what some now term “femicide,” the assassination of women.
A. Sociolegal Status, Issues, and Lifestyles
Specialists who work with homosexual populations reckon that they constitute 10% of the population in Costa Rica. Homosexuality has been and still is, though to a subtly lesser degree, a taboo subject. There are gay men and lesbian women in all walks of life, government institutions, the Church, etc., and in all social classes. Many live their lives quietly, minding their own business, and not congregating; others socialize in gay or lesbian bars; some form similar-minded groups (e.g., feminists, activists). But this country is homophobic, and until some individuals began to study gender theories, and later others began to work in preventing the AIDS epidemic from spreading, homosexuality was treated as a pathology, with many stereotypes in the public mind and media.
Homosexuality is not a crime in the Penal Code of 1971. Before these reforms were introduced, the punishment for sodomy was one to three years in prison (article 233). Since 1971, there has been no basis for the prosecution of homosexuality, as long as it occurs between two consenting adults and passive participants are more than 17 years of age. Prostitution is not considered a crime either, unless it is practiced in a “scandalous” manner. There are strict laws against pimping (owning a brothel) and inducing minors to practice prostitution. Most convictions are for these two reasons. In order to prosecute an adult prostitute, there must be some other infraction, such as moral indecency, public scandal, suspicion of drugs, or vagrancy. Unlike female prostitutes, male prostitutes are not regulated by law, nor are they required to be tested for venereal diseases.
In many ways, in recent years, the subject of homosexuality has begun to come out of the cultural closet. This is mainly because of the political work done by both groups and to the particular ability of certain individuals who took advantage of the VIH/SIDA (HIV/AIDS) pandemic to make visible the situation of gay men, and of men who have sex with men. Through the work of a now-extinct NGO, ILPES (Instituto Latinoamericano de Prevención y Educación en Salud [Latin American Institute of Prevention and Health Education]), many research projects were carried out about homophobia, stereotypes, and sexual behavior between men in prisons, among male prostitutes, and transvestite prostitutes. Through their work with support groups of gay men, and the promotion of prevention and the use of condoms in bars and places frequented by gays, the incidence of VIH was reduced in this group. Through their work with lawyers, doctors and hospital workers, policemen, prison workers, university professors and students, and many other groups, the real situation of gay men was made visible, as well as the homophobia inherent in this culture—and in every individual, including gay men themselves. One of the aims of this work was to change the discriminatory attitude to a more tolerant attitude towards gay men. Still, at present, homosexuality is a taboo subject, and gays have suffered rejection, invisibilization, violence, and even death in recurring gay-bashing episodes.
In one of the earlier publications by Jacobo Schifter, director of ILPES, he described very clearly how homophobic attitudes amongst homosexual men worked to their detriment. There existed total mistrust between them: They would never reveal their full name and even less where their family lived or their place of work, so that an ex-lover would not be tempted, in a fit of rage, to call the family or work and reveal his true identity. Neither would they reveal who their current lover is, because they would face a barrage of insults about him: “He is una loca (a queen),” “He has slept with half of San José,” “He has AIDS,” etc. The ultimate violence in this chain of events, including stealing or destroying each other’s property at parties, is the murder of gays by other gays. Between 1988 and 1996, 25 gay men were tortured and then murdered by the chulos (pimps) that they had taken to their homes. Another violence that gays faced was with the police. These would keep vigilance on the gay bars, and at any pretext, they would charge in and beat up the gays inside and make roundups. One explanation for this could be the fact that some of the police are closet homosexuals; another could be that they share the same masculine ideology where women are not involved. They live in close physical contact with each other: They work, eat, sleep, socialize, and live together for long periods. This creates a particular erotic and dangerous dynamic within the repressive function of the police.
Another aspect of gay culture is the emphasis on youth and physical beauty. Anyone who does not fit this model is rejected without mercy. Aging is feared. In Costa Rica, to be gay is to be an adolescent, and gays are discouraged from going to gay bars and dances after they are 30. Forty is considered to be old. Relationships are short lived; even when both profess to being in love, the relationship does not transcend the passionate phase, and soon, one or other of the partners begins to look elsewhere.
During the 1950s and 1960s, gays met in distinct public places to have casual and anonymous sex: saunas, parks, cinemas, and urinals. This pattern, though still in force, has changed because of the creation of bars for gays and lesbians. This created a pattern where some gays would seek out sexual partners, but many still sought encounters in public places. Although the repression has diminished, the sexual pattern of anonymous sex continued, principally by very isolated or by closeted gays. Bisexuals and married men sporadically frequent these places. Contact is made by the individuals touching their genitals, a common practice in heterosexual men in this country, but with the particular connotation with gays of “you can have all this,” or by jangling their keys, a sign that they have a car or a house where they can go to. After this, verbal contact is made. Frequently, in the less illuminated parts of parks or urinals or narrow passages between houses, men masturbate each other or practice fellatio. Penetration and group sex take place in safer locales, like cinemas. Middle-class bisexuals and gays frequent saunas more than the other public places. Public spaces are also places for sexual workers to practice their trade. Muggings and stabbings are common occurrences, as well as police roundups. This violence and danger is part of the erotic attraction for many of these men who initiated their sexual life on the street, “I like the fear . . .,” “I want to participate in the danger . . .,” two men told Schifter (1997).
By 1998, violence had noticeably increased in these public places, in part, because of the appearance of the chapulines or “locusts.” Locusts are male and female juvenile gang members who mug and rob people, and are compared to swarming pests. They are very antagonistic to gays and are responsible for several murders of gays in the last few years. They, like the gays, have taken over public places to impose their own culture of sex, robbery, and death. At some vague time during the past few years, the locusts ceased to be mere delinquents and became part-time cacheros. Many of them stopped mugging gays and began to have anal sex with them and then rob them (Schifter 1999).
In the interviews carried out in the El Salon ILPES project, both cacheros and locusts had the common history of childhood abuse. They were all beaten by their fathers; many were sexually abused. Some lived with mothers who were prostitutes or with alcoholic fathers who abused them sexually. The locust from the smallest family had seven siblings and the one from the largest had 18. The mothers, fathers, or stepfathers are often unemployed, often alcoholic, or/and addicted to drugs, lost their patience, and vented their rage on their children. These adult men were the most sadistic and brutal and imposed their power physically. No longer able to provide food regularly for their families, they maintained their macho privileges through violence. Thus, the locusts’ school of violence is closely related to gender issues; it serves to preserve gender imbalances. Most of these youngsters had been thrown out of their home and had made the streets their habitat. They make a living from robbery, the sex trade, and drugs. Inured to the penetration of their bodies by violent and inept parents or guardians, their bodies became a battlefield. The locusts are obsessed with orifices. Theirs must remain closed to the world, those belonging to others are ready to be taken, the same as open public places. To the locust, a homosexual is someone who allows his body to be invaded. Why do they, then, copy the cachero’s behavior? If they have chapulinas in their own group, why did they turn from criminals to sex workers? According to Schifter, the relationship developed through sharing the same physical spaces. But, more importantly, for the first time, someone was looking at them and finding them attractive underneath their shabby clothes. Attractive well-endowed locusts would find new benefits. Now a new class was emerging: the handsome chapulines with large penises and big bottoms. Those who did not satisfy the demands of the market remained as intermediaries of the “good beef.” This changed the culture in the parks and public places. For a few hours each day, undocumented delinquents, drug addicts, and criminals, who were despised and feared by decent people, became public porn stars. A new Cinderella was born. The new heroes could now have sex with their victims and make good money out of them. Some of them had queues of men waiting to perform fellatio on them (Schifter 1999).
Gays and locusts might share the same spaces, but there exists a clear clash of cultures. They do not speak the same language. For gays, with their sexual model of the body and its pleasures, and locusts with their vision of the vulnerable body, communication is a tortuous road. Some gay murders have been committed by locusts. These crimes go beyond simple robbery. They are forms of torture that are impregnated with a profound degree of rage. One gay was killed by three men; they had amputated both arms, one leg, and his penis. They had cut the flesh on his arms and legs to shreds, and he had 12 stab wounds in his rectum. Ten chapulines were asked to explain this and other equally violent murders, some of them having been at the point of killing—or have actually killed—a gay client, or pagador, as they call them. Some agreed that the motive was robbery. Another said that they were premeditated, especially when there are three perpetrators and the assault takes place in a hotel or the victim’s home. These crimes occur when the locusts have taken a combination of drugs: crack, marijuana, and alcohol. “The three victims discussed were stabbed in the ass, the mouth, and the dick,” says one. “This means the locusts wanted to punish them for being gays, for letting themselves be fucked.” However, there are triggers to this violence. If the client cheats them of money, when they touch them improperly, when they are humiliated, when they are feminized or asked to do “women’s things,” like kissing, allowing penetration, giving oral sex, if they are asked to wash dishes, or to help in preparing food for dinner like chopping onions.
For the locusts, clients are a source of income; unlike gays, sexual pleasure is totally irrelevant to them. The majority are heterosexual and do not enjoy sex with men. When a client establishes a relationship with a locust, the latter expects some form of compensation when the relationship is broken off. Juan killed Victor when, after three years of being his client, Victor found himself another locust. Gerardo cut off one of his client’s testicles when he found out that he was paying another locust more than him.
Another group studied by ILPES is the homosexual transvestite prostitute community in San José. Schifter (1997, 1999) maintains that an analysis of the Costa Rican transvestite community shows an elasticity in sexual orientation that challenges the essentialist theories. The men who practice transvestism have different sexual orientations and different degrees of femininity and masculinity. Shifter believes that the physical space, in combination with the paqueteo (the packaging used in order to pass as women), are very important in producing changes in sexual orientation. Many transvestites are heterosexual men, married and with children, who like to dress as women, but do not have sexual relations with men. In Costa Rica, this group is the most concealed. They do not form part of any community, nor are they prostitutes, like some homosexuals.
Most of the transvestites contacted became aware of their orientation around 12 years of age. Many of them were initiated sexually by an older man; some say they wanted that experience, although others were obviously abused. Prostitution is their only means of making a living. They are thrown out of their homes and find no other option. They spend a great deal of their earnings on their clothes, make-up, and wigs. They have clothes for work, others for shows, and more-ordinary gear for everyday activities. The padding of hips, legs, and breasts are done with foam, rolled-up toilet paper, or cloth. Others use hormones, particularly contraceptive pills, which can be bought over the counter. Some use Depo-Provera, or whatever pill is available.
They share living and workspace, often cramped apartments, or the “bunker,” a heavily secured row of rooms. A minority of transvestites come from fairly affluent middle-class homes. One of these, a doctor’s son, carries out his trade unbeknown to his family. One day, one of his father’s colleagues, another doctor, came to buy his services and did not recognize him dressed as a woman with a blonde wig. Originally, they lived and worked in a poor red-light area of the city and attracted poorer clients. When they migrated to a lower-middle-class area, they attracted more-affluent clients.
Previously, this area was used by female prostitutes; little by little the transvestites took over, and the prostitute’s clients changed from heterosexual to bisexual orientation, in a slow process that was begun by the more feminine-looking transvestites passing with their clients. Eventually, the female prostitutes left, leaving the whole area to the transvestites. It was when cocaine became easily available and was used by the clients, that they allowed themselves to be touched and fondled by the transvestites. They began to say that they “liked it more” than with the female prostitutes, and began to recommend their friends. Some of the clients are members of Parliament and professional people.
But life is hard, and every night they expose themselves to insults, stabbings, being thrown bags of urine or excrement, or stones or bottles by men who make a sport of this violence. The priests denounce them in church, together, according to them, with other “scum,” like homosexuals and prostitutes. Some defend themselves by throwing stones at cars. Much of this takes place in front of the houses where people have lived for 30 or more years; some of the neighbors have organized themselves in order to change the situation, but to little avail.
In 1990, when Schifter (1998) asked transvestites the number of sexual contacts that they had had in their lives, the average was 9,371. In 1997, the average was 4,835. In the year before the survey, the average was 830.4, making that 15.9 sexual contacts per week. In the month of the interview, there were 44.8 contacts, that is, 11.2 weekly contacts. Some transvestites say they make, on average, six contacts nightly. If we calculate that there exist 100 to 150 transvestites in San José, and each one has an average of four sexual partners, we can reckon that about 600 men use their sexual services in one day (Schifter 1998).
Many clients treat the transvestites as women with a penis, unlike their own permanent lovers, who treat them as women and do not want to see their penis. The majority of these partners were heterosexuals, some with children. Some still consider themselves heterosexual, others homosexuals or bisexuals. Interestingly, the transvestites do not consider their partners to be homosexuals.
Male Prostitution and Bisexuality
Another study by Schifter (1998) focused on a very specific sexual culture within the realm of male prostitution: the young men of a lower-middle-class brothel catering to pederasts. These youths are neither homosexual nor bisexual, in the sense of being attracted to only men or both men and women. The only characteristic that identifies them as bisexual is their sexual behavior while prostituting themselves. This places them within the culture known as cachera—men who have sexual relations with other men, but who are heterosexual in all other respects. Some of them are students (at school) or professionals, and some still live with their families, while others have moved into their own homes. The youths are between 13 and 27 years of age. A few live in a brothel, but the majority arrive at night to attend to clients. For some, the money is spent on crack, alcohol, and luxury extras. Some of them help out at home. The clients are bisexual in their orientation. Most of them are married men with children, who are completely “in the closet,” leading a heterosexual life in public, with occasional visits to the brothel. Some clients are homosexuals. They are made up of nationals and foreigners.
The situation of lesbians is different. Sporadically, they were included in the ILPES project. But, as in other countries where gays and lesbians have fought together for homosexual rights, lesbian women ended up supporting the men, but this was not reciprocated. There is a new NGO, CIPAC (Centro de Investigaciones para América Central—Derechos Humanos de Gays y Lesbianas [Central American Research Center—Lesbian and Gays’ Human Rights]), which is changing this pattern by working shoulder to shoulder with both groups. But here, lesbians are analyzing themselves from the perspective that they have more in common with other women than with men, gay or not. If women, in general, have been invisibilized in history, even more so have lesbian women. Even in the feminist movement, made up of a high percentage of lesbians, the subject is not discussed, consequently producing much tension in the groups.
For several years in the 1980s and early 1990s, the lesbian group, Las Entendidas, published a journal called La Boletina, with poetry and information, and analytical articles about lesbianism, feminist theories, and about lesbian women’s lives. The work of Ester Serrano, based on in-depth interviews with nine lesbian women, set out to find out how some lesbians have established groups and what this has meant for them. All these women learned in their childhood that lesbian women suffer, are problematic, are abnormal, and cannot be “good” mothers. They also learned that they should make themselves invisible. All the women interviewed had absorbed these homophobic sentiments. The first gay bars opened in the 1970s, and for the first time, gays and lesbians had a place for themselves where they could enjoy themselves, and where they could meet and be with other lesbians openly. However, these bars were populated by young people, and for many older lesbians, they were aggressive, patriarchal places. Not only this, in those early years, these bars were secret places, where gays or lesbians had access only by asking to see the owner. They were regularly raided by the police. In this context, “butch” lesbians formed into a group called “The Buffaloes,” who came together as protectors of the other “weaker” women. They made a buffer between the “femme” women and the police, receiving the blows, having their noses broken. Another strategy created in the still-existing La Avispa [The Wasp] bar, was to turn a red light on as a warning of a police raid. Immediately, the same-sex couples would change partners and pretend to be heterosexual.
All the lesbian women interviewed, with some exceptions, lived in the closet in relation to their families, and all hid their identity at work. This changed as they became aware of their rights, particularly in the younger generation. The older lesbians were more circumspect because of the generalized homophobia, and to the fact that the fight for gay rights had not taken place. In the beginning of the 1990s, gays and lesbians began to celebrate Abril Saliendo del Silencio [“April Coming Out of the Silence”], which publicly celebrated the existence of gays and lesbians in Costa Rica. From this time on, they decided to carry on dancing with their same-sex partners, raid or no raid, marking a hiatus in their history. The feminist movement, the gay and lesbian movement, and the distinct lesbian congresses in Europe, North America, and Latin America have also strengthened the lesbian women in Costa Rica—although it is important to emphasize, no lesbian working in a state institution has come out openly about her identity.
Transvestites have been discriminated against and scorned. Often their own families throw them out of their home. Since the 1990s and the work of ILPES in the project of men who have sex with men that was centered on prevention of HIV/AIDS, some transvestites became activists and began to defend their rights. (See discussion of transvestites in the preceding Section 6.)
A. Coercive Sexual Behaviors
Child Sexual Abuse, Incest, and Pedophilia
From the 1980s on, child sexual abuse and incest have been studied in Costa Rica and, as a consequence, different nongovernmental organizations specialized and grew around this subject. It is estimated that one out of three women have suffered some kind of sexual abuse before the age of 18, and one out of five men. Twenty years later, laws to prevent this abuse have been created, and a campaign organized by governmental and nongovernmental institutions and organizations have trained doctors, lawyers, social workers, teachers, and other professionals to detect this social cancer in children, and to refer the cases for investigation. Many abusers are now jailed. There are signs and information in highways, shops, and institutions, as well as television ads, that denounce sexual abuse. The effects of incest and abuse are devastating, and this is now taken into account when treating female mental patients, as well as other persons in institutions like jails.
Through the work of organized feminists in government and nongovernmental organizations and universities, the Law Against Sexual Harassment in the Workplace and in Educational Centers was created in March 1995. The consequences can lead the abusers to be suspended or fired from their work. Sexual harassment was a serious problem for women in a culture that has permitted men to stare, whistle, make lewd remarks, and even touch women in the street or in public places. This was called piropos, or flattery, part of the machistas behavior permitted prior to the development of human rights and feminism.
The sexual exploitation of children and adolescents in Costa Rica is a social problem only recently recognized, even though it has a long history in the country and is documented in various texts dating back to the 18th century. Until 1997, the criminal code currently in force did not penalize the corruption of minors (premature and perverse sexual acts) if the victim had been “previously corrupted.” Nor was there a legal statute against child prostitution. Through the dynamic work of NGOs (Casa Alianza, the Paniamor Foundation, Ser y Crecer Foundation, and the Procal Foundation), Costa Rica began to analyze the situation and to change its legislation.
The sexual exploitation of children occurs within the family (incest), or outside of it (prostitution, for example). But both cases involve a variety of diverse interrelated factors. For girls, several studies have shown that the vast majority entered into prostitution as a result of living on the street. In this sense, running away can be interpreted as being expelled from the family, as this act is often associated with abuse, abandonment, and neglect. In 1996, in the World Congress Against Commercial Sexual Exploitation of Children, held in Sweden, nongovernmental organization and the End Child Prostitution in Asian Tourism campaign (ECPAT) made a specific reference to the problem in Costa Rica, namely, that it attracted many tourists and residents from the United States and Europe who “take advantage of their stay” to participate in the local sexual exploitation of women, girls, and boys.
There are few studies of child prostitution in Costa Rica. Among these are the works of Tatiana Treguear and Carmen Carro (1994, 1997), who carried out two qualitative studies on the experiences of prostituted girls. The 1994 research was part of a Central American project with 30 prostituted adolescent girls between the ages of 13 and 17 in San José. In 1997, these same authors carried out a broader research endeavor with 50 prostituted adolescent girls between the ages of 9 and 17. This work addressed the risk factors associated with prostitution and provided an analysis of the reasons why they left home and their current living conditions. Sexual abuse as an antecedent of sexual exploitation was very common, given that 41 of the 50 girls reported that they had been sexually abused. Other factors that make Costa Rican children and adolescents vulnerable to prostitution include the extreme poverty of 10% of the population and the high percentage of adolescent girls who do not attend school. In addition, many women have their first child between the ages of 15 and 18, and 41% of all children are born to single mothers. Other factors include the consumption of drugs and alcohol.
In the last 15 years, a new phenomenon in the country has been the appearance of children in the streets. The “street phenomenon” stems from poverty, urban sprawl, and lack of alternatives, and is related to mistreatment and violence within the family. In some cases, boys and girls abandon their home for the street because they have nowhere else to go or they have been forced out. In other cases, in order to survive, these children must find the resources to do so. Once on the streets, the children forge new emotional ties in the form of couples or peer groups, bonds for affection and protection that help them to survive in an environment characterized by abuse, humiliation, and persecution. Drug consumption is often linked with life in the streets and also plays an important role in sexual exploitation, because many boys and girls continue with their addiction while they are being prostituted. Alcohol and illegal drugs, such as crack, cocaine, and marijuana, as well as paint thinner and glue, are staples in this population.
Another important aspect in analyzing drug consumption is how it relates to gender. Given that prostitution is primarily associated with the female gender, the challenge is how to interpret drug and alcohol abuse of girls and women. Studies demonstrate that the risk factors associated with substance abuse among women focus on violence, child sexual abuse, and rape. Specifically, they highlight four risk factors associated with especially difficult situations: sexual harassment and abuse, prostitution, unemployment and the prevailing need for support, and domestic violence (Claramunt 1999). These youths use their addiction as a way of numbing their pain and dealing with the situation. A second important element that contributes to high rates of sexually transmitted diseases, including HIV/AIDS, is the absence of protection measures associated with high intoxication levels and the lack of power over prostitution customers.
Those who sexually exploit children and adolescents are supported by many social sectors in Costa Rica that tolerate and justify the sexual marketing of children and adolescents. They come from a wide range of social groups and classes. They are white-collar workers, laborers, relatives, businessmen, political leaders, government officials, and police officers. Over the last few decades, Costa Rica experienced a rise in the sex tourism so prevalent in many Third World countries. Costa Rica’s principal income comes from tourism, and the attraction for sex tourists was the low cost and young age of the boys and girls, as well as by the ease of prostitution. Thousands of pedophile tourists learn about Costa Rica through the Internet and magazines, sample guides, or catalogues that include pictures of naked girls and boys, and maps or directions that point out the location where the children are. These tourists are aided directly in the street or bars and hotels by taxi drivers and waiters, who contact the pimps or the owners of prostitution houses. In some cases, these places are known as “cradle houses,” because the children that live there are given food and clothing in exchange for prostitution. The greatest demand for girls and boys are the ports on the Pacific and Atlantic coasts where expensive boats and yachts arrive.
The organization Casa Alianza has been the most dynamic in making visible and in denouncing the sexual exploitation of children and adolescents in the country. Casa Alianza, directed by Bruce Harris, established itself in the country in 1996. It regularly receives denouncements and hate mail, which are filtered and investigated and then passed on to the Prosecutor’s Office of Sexual Crimes. This office was created in 1998, but it has not been institutionalized in the Judicial Power and has no resources. Casa Alianza managed to obtain funds from the British Embassy and since then, there are about 50 people condemned, arrested, or waiting trial for sexual crimes. Two thirds are Costa Rican and one third are foreign. Casa Alianza has received more death threats in Costa Rica than in Guatemala, where it also has a program with street children and where there is more overt violence. When sexual exploitation is investigated, many powerful financial interests are touched. In 2002, there were 110 convictions, which included pimps, intermediaries, and clients.
In 2002, five members of the Costa Rican Pedophile Association were condemned, but unlike Chile, which created a Pedophile Unit, which as of April 2003 has discovered 18 pedophile networks in Costa Rica, there has not been one follow up in Costa Rica. According to Harris, there are girls brought to Costa Rica from the Dominican Republic, the Philippines, Bulgaria, Russia, Colombia, Nicaragua, and Panama. They are taken to exclusive clubs, where 60% of the clients come from the United States and the rest from Europe and other countries. These are men between 55 and 60 years of age. In San José, there are an estimated 3,000 girls, nearly all between 9 and 10 years of age. Similar estimates apply to the trade in the ports on both coasts. The average price of a virgin girl is about $400.
The pimps work in families; when one member is jailed, a daughter or son continues the activity; when they are arrested, a cousin carries on. Women are the main recruiters in the case of the girls, sometimes friends of the girl take her and receive a commission. These women are motherly; they feed and take care of the children. There are other pimps who distribute their cards in poor areas, telling the youngsters that if they want to earn some money to call them. Many do. These children do not do this because they like it; they do it to be able to eat. The Costa Rican Pedophile Association frequented the poorest areas in San José, where, for $15, these children could eat for a whole week.
Child pornography is not illegal in Costa Rica, which is a big problem, as Harris believes that there is a direct link between the use of pornography and the subsequent use and abuse of children. There was a university professor, who also worked in the prestigious Arias Foundation (created by ex-President Oscar Arias, a Nobel Peace prize winner), who had 6,000 pictures of child pornography in his computer at work, but he could not be prosecuted, and still continues as a professor. Distribution of child pornography, but not possession, can be prosecuted.
In spite of the Catholic Church’s prohibition, the attitude towards birth control is open. People can buy condoms at supermarkets and at pharmacies. The pill can be bought over the counter at pharmacies. However, for the last five years, there has not existed a national campaign for birth control, and although the Social Security System provides birth control services, women in many communities do not attend these clinics, due in part to ignorance, timidity, or lack of insurance. Adolescents generally do not attend the clinics, for similar reasons as the adult women, but also because they are often turned away and told not to have sex until they are married—clearly reflecting the attitude of healthcare workers about adolescents and their being sexually active. However, the fact that 40% of pregnancies are unwanted or unplanned in Costa Rica reflects other emotional, gender, and cultural inhibitions in relation to using contraceptives. It is known that many men do not want to use condoms, and that some do not allow their partners to use protection. There is a waiting list for women waiting to be sterilized after the 1999 Reproductive Health Decree, which allowed women to be sterilized on demand, without their husband’s or the doctor’s permission. The middle-class consult their private doctors about contraceptives.
More than 800 teenage girls age 14 or younger, some as young as 12 years old or even younger, have babies every year. This has been the average number for five years. In 2000, it reached the peak number of 956. PANI (Patronato Nacional de la Infancia [National Institution for the Protection of Children]), which attends these girls, says that they are the victims of sexual abuse. And 15,000 adolescents over age 14, have children every year. The PANI is preparing a campaign to prevent sexual abuse. The CCSS (the Social Security System) initiated in April 2003 a new campaign directed at this teen population, with the aim of postponing early sexual encounters. More than 50% of teenage mothers conceive during casual sexual encounters; and when it is with “boyfriends,” the relationship is fragile. Sixty percent of these pregnancies take place between 14 and 16 years. Many are high-risk pregnancies. Of all the children that die each year before they are one year old, 55% are premature, and of these, 74% are children of women who are under 20 years of age. There are hotline telephone programs for people to call in about their sexual problems—73% of calls in the year 2002 were made by adolescent women.
In January 2003, Costa Ricans were moved by a story published in the major newspaper, La Nación, about a 9-year-old girl who had been sexually abused and was pregnant. The newspaper article read as follows:
Nine Year Old Girl Three Months Pregnant. Alarm at Child’s Pregnancy
Turrialba. There will only be 9 years of difference between this mother and her child. This small generational gap will probably make them share children’s games more than anything else. The reason being that Rosa (fictional name given in order to protect her real identity) today is 12 weeks pregnant. And she is a 9-year-old girl. This case has moved Turrialba (the town where Rosa lives). Daughter of Nicaraguan immigrants, coffee pickers, Rosa is the victim of abuse by a 20-year-old local farm worker. As a consequence, her physical and emotional state is very delicate. So much so, that the doctor’s at the William Allen Hospital, have decided to keep her interned in order to observe her pregnancy. The doctor’s have asked that this case be in the hands of the Ministry of Health. —Ramiro Rodríguez, reporter, La Nación. (Miller 2003)
This story has created a major controversy in both her homeland of Nicaragua and in Costa Rica—lawyers, physicians, Church leaders, and feminists weighing in with passion. This time, it was not because there was a proposal to amend the abortion statute in the Criminal Code, as was the case in 1993 when a Member of Congress, Nury Vargas of the PUSC (Partido Unión Social Cristiana), presented a law project in the Legislative Assembly to modify article 121 of the Penal Code. That proposal would have added a paragraph to allow abortion in the case of incest or rape. The proposal was rejected. The Catholic Church and public opinion also rejected the initiative, and Nury Vargas left the Congress under duress. This time, it was about the fact that abortion was rejected by the authorities, alleging that the consequences of an induced abortion would be more negative than her carrying the pregnancy to term and having the child. But there was another element: Rosa’s parents were not informed that in the actual legislation there exists the possibility of therapeutic abortion when the “mother’s health” is endangered. Rosa was moved to a hospital in the capital and kept away from her parents.
Meanwhile, feminists groups discussed this very delicate problem, and some presented a document with clear proposals in relation to Rosa’s case. It was clear that there would not be an abortion for her, and it took a delegation of Nicaraguans who came and took the child to Nicaragua, where eventually, after much controversy there, an abortion was carried out in a private clinic.
This case has been positive for diverse reasons. It broke the silence on the subject of abortion in a country where it is practiced in secret, either in private clinics or by other means. Since Nury Vargas presented her proposal and was rejected, a mantle of fear, and thus, of silence, has hung over the subject. No one has wanted to bring it forward, not even feminists, except in reference to the need to do more research on the subject. Today, different women’s groups, including government institutions, are discussing it, though behind closed doors. In May 2003, a forum on the subject of abortion, organized by and directed at feminists and NGOs, was held in order for this group to begin to formulate a clear standpoint.
The actual legal situation regarding abortion in the country is as follows: Induced abortion is classified as a crime in the Penal Code of 1970, included in the crimes against life. The penalties vary according to whether an abortion has been carried out with or without the woman’s consent, and depending if the fetus has reached six months of gestation. Abortion is not punishable only when the woman’s life is in danger, and in this case, the procedure can be carried out by a doctor or an authorized obstetric nurse. However, there are many doctors who, for reasons of religious faith, will not carry out an abortion.
The law in the country is restrictive and criminalizing, punishing women who decide to abort and those who carry out the procedure. Doctors who suspect that a woman has provoked an abortion are obliged to report this to the OIJ (Organización de Investigación Judicial [Organization of Judicial Investigation]). Years ago, operations were carried out periodically to detect and jail the doctors who practiced abortions. Very few were jailed; some left the country. Very few women were jailed also, and at the present moment in 2003, there are neither women who have aborted nor doctors in prison. However, a lay woman accused of carrying out abortions is serving a three-year sentence. She is an untrained midwife, with a lot of practical experience in her region.
This permissive attitude shows a more tolerant stance on behalf of the medical culture to a reality that affects the female population. But the subject is taboo, and abortions are still clandestine experiences affecting women’s individual and collective health. At an individual level, it affects a woman physically, emotionally, and psychologically because of the complications that could present themselves, and because of the danger and loneliness a woman faces. At a collective level, the community’s health is affected when the impact is not made visible by the underrecording of cases; when appropriate reproductive health services to attend the need for contraception are not met; when post-abortion services are not available; and when women’s sexual and reproductive needs are not recognized. These are needs that Costa Rica must address if it is to remain as a member country of the United Nations resolutions of the 1994 Conference in Cairo.
In spite of the fact that the United Nations Human Rights Committee (April 1999) recommended that Costa Rica’s “legislation should be amended in order to introduce exceptions to the general prohibition of all abortions,” the actual Costa Rican Legislature has the intention of increasing the penalties for abortions. This decision is backed by some articles in the Constitution, which point out that the religion of the State is Catholic, Apostolic, and Roman, and that human life is inviolable.
The Law Project under discussion in the Committee of Juridical Affairs of the Legislative Assembly has introduced the expression “the product of conception,” eliminating the idea of the fetus. It preserves the image of abortion as unacceptable, but it incorporates the following modifications: a) the requisite for informed consent has been eliminated, and b) the figure of the comadrona (midwife) is included. In another attempt to control and restrict the right to choose, in November 2002, Article 379 of the Penal Code was modified and included all “those who advertise procedures, instruments, medicaments or substances destined to provoke abortions,” would be fined.
The Gender Analysis Group of the Penal Code Project, headed by INAMU (Instituto Nacional de Asuntos de las Mujeres [National Institute of Women’s Affairs]), and confirmed by government and nongovernmental participation, has developed an alternative document, which will be presented to the Committee of Juridical Affairs in 2003. It includes a norm in relation to abortion with impunity, which takes into account as not punishable the interruption of pregnancy in the following cases: when the person is under 12 years of age; in the case of rape; and when it is with informed consent and until 12 weeks of gestation. This would be an addition to the existing figure of therapeutic abortion.
Abortion in Costa Rica is a problem of public health; this is evident when studying the following data for the period 1990-1994:
- In 1990-1994, 12.4% of maternal deaths were because of abortions.
- In 1984-1991, the National Health Services—CCSS (Caja Costarricense de Seguro Social)—serviced an annual average of 8,669 hospitalizations for the consequences of illegal abortions.
- In 1984-1991, the rate of induced abortions per 1,000 women between 15 and 49 years in the same period was 10.36% (Brenes 1995).
- According to CCSS data for 2000, there were 9,710 abortions in Costa Rica’s main hospitals.
However, these figures are aggregates, which does not permit us to see whether they were spontaneous abortions or complications because of illegally induced abortions. Also, abortions in private clinics are not registered.
It is important to point out that there does not exist a protocol in the health-system hospitals for practicing therapeutic abortions in case the woman’s life is in danger. This is pointed out in the Parallel Report of the CEDAW, which will be presented as a recommendation in June 2003.
At the present time, women in Costa Rica are ignorant about the possibilities of having therapeutic abortions in case their lives are in danger. It is known that women receiving chemotherapy have not been informed of the possibility of abortion when faced with an unplanned and unwanted pregnancy. Instead, their treatment is suspended until the pregnancy is full term, putting both lives in serious risk.
Costa Rica does not have a problem of overpopulation. In fact, during the coffee, sugar cane, and other harvests, there was always a shortage of labor until the Nicaraguan immigrants came. However, there are certain groups, adolescent women, Indian, and other poor women, who are the target of birth control programs. There are a few women who have as many as 18 children, but they are the exception.
A. Sexually Transmitted Diseases
There has been a gradual reduction in the reporting of most STDs, particularly gonorrhea, whose incidence plummeted from 433.8 per 100,000 population in 1982 to 123.7 in 1990, and 68.6 in 1995. The incidence of syphilis also decreased from 99.8 per 100,000 population in 1982 to 54.3 in 1990, and 44.7 in 1995. The persistence of congenital syphilis in noteworthy, with the number of reported cases each year somewhere between 90 and 150.
At the end of 1987, the national record of AIDs cases showed for the first time that homosexual and bisexual men were the most affected by the epidemic. During the next few years, this pattern worsened, and of the 1,000 cases recorded by 1996, 70% were homosexual and bisexual men (Schifter 1998).
In 1990, the first National Survey on AIDS was carried out with research on Costa Rican sexuality, including questions about when they first initiated their first sexual relations and with whom, the use of condoms or contraceptives, and so on. This was the first investigation in Latin America that clearly showed that knowledge and information and praxis did not have a perfect relationship. People knew certain things about AIDS, but did not put them into practice. A very small segment of society practiced safe sex, because several cultural factors prevented them from using condoms. What was discovered is that men have ten times more sexual partners than women, that the age of initiation had not varied over the last 40 years—it varied in only 15% of men and in 16% of women—but what had changed was the person with whom they had their first experience. Generations back, men had their first sexual encounter with a sex worker; nowadays, this only applied to a small minority. Drugs and alcohol were elements linked to unsafe sexual practices, as well as a great deal of sexual ignorance and prejudices in young generations. In 1991, the first survey of men who have sex with men in Latin America was carried out in a community with homosexual practices, where high numbers of unsafe practices were discovered. Forty percent of the men engaged in unsafe sex. This 40% was 10 times higher than studies in the U.S. found. Many of these men also had sex with women, leading to a considerable number of heterosexuals being infected with HIV.
In the 1990s, new NGOs appeared with the specific aim of combating the VIH/SIDA epidemic. ILPES was principally directed at the gay community and at men who have sex with men. Fundación Vida offered psychological support for HIV persons. Members of Triángulo Rosa were activists who worked with human rights. ASOVIHSIDA (Asociación de Personas VIH/SIDA [Association for Persons with HIV/AIDS]) was an association made up of HIV-infected persons, which offered legal advice and also worked in human rights. There was a prevention program in the Ministry of Health, and a national committee of governmental and nongovernmental organizations. However, by 1998, these programs had disappeared because of a lack of funds, with a couple of exceptions. In this period, gay activists won the battle for the right for persons with HIV to receive the medical cocktail to prolong their lives from the national health system. In 2003, Costa Rica received $4 million from the Global Fund to combat the epidemic.
According to the Fundación Vida, there are 2,340 cases of AIDS diagnosed by the Ministry of Health in March 2003; these are the cases being treated in the national health system. Many people are being treated privately and their cases are not being reported. Experts estimate that there could be around 25,000 HIV-infected persons in the country.
[Update 2002: UNAIDS Epidemiological Assessment: No epidemiological assessment is available for 2002.
[The estimated number of adults and children living with HIV/AIDS on January 1, 2002, were:
|Adults ages 15-49:||11,000||(rate: 0.6%)|
|Women ages 15-49:||2,800|
|Children ages 0-15:||320|
[An estimated 890 adults and children died of AIDS during 2001.
[At the end of 2001, an estimated 3,000 Costa Rican children under age 15 were living without one or both parents who had died of AIDS. (End of update by the Editors)]
Sexologists are definitely a new phenomenon in Costa Rica, and consequently, the subject of sex is treated in a more open manner on television and radio programs, in magazines, and in diverse literature. Sexo Sentido [Sex Sense], a very popular radio program aired by the University Radio (University of Costa Rica) is very open in its discussions of sexual topics and issues. Different sexologists who appear on Sexo Sentido have studied sexology in Mexico, California, Argentina, and other places, and have varied perspectives.
Viagra has made penile dysfunction a subject that can be discussed and treated. At the same time, articles about female sexual problems and therapy, and about the female Viagra or the clitoral pump to stimulate women’s arousal appear in magazines and newspapers (La Nacion 2000). We could say that at last the truth is coming out about the sexual misery lived by so many people. However, the problem that I detect is that centuries of silence and ignorance cannot be breached merely by the high production of new information or by the new discourses about the right to pleasure. What is not named does not exist, and for many women, the very process of naming is the very first step of appropriating their bodies and their genitals. On the positive side, the state of men’s and women’s sexuality in this country is not that different from others, but the ice has been broken on the subject of sexuality, which is the beginning of breaking the silence.
It is impossible for men, and particularly women, to identify or acknowledge that they have a sexual dysfunction when their culture gives them no basis for comparison. For instance, a 1992 study found that two out of five women had never experienced orgasm. Although sexologists and therapists are aware that the most common female dysfunctions are lack of feeling and arousal and the inability to reach orgasm, it is likely that 40% of Costa Rican women will not even be aware of their dysfunctional sexual relationships. In a culture that has a centuries-long taboo on the discussion of sexual matters, it is also likely that men will not acknowledge any problem with premature ejaculation and lack of erection. There are, however, some positive signs that Costa Ricans are becoming more aware of and willing to talk about what constitutes normal, healthy, and pleasurable sexual relations for both women and men.
A. Institutes and Programs for Sexological Research
In 1988, Javier Ortiz, a trained sexologist, created Fundación Gaia (Gaia Foundation), a center for health, sexual therapy, nutrition, and so on. He had the first television program where people came to talk and the public phoned in. For the first time in Costa Rica, subjects such as orgasm, lack of orgasm, and premature ejaculation were discussed. He published a book, The Hundred Questions and the Gender Rainbow, where he details the most frequently asked one hundred questions, that take into account: sexual desire, the orgasms, female and male ejaculation, pregnancy, birth, and postpartum.
Mauro Fernandez, a gynecologist and sexologist, founded the Costa Rican Sexologist Institute in 1990. They do not train therapists, but guided by Masters and Johnson’s research, they concentrate on sexual education, and also on research. They have produced Lola and Paco: A Sexual Education Manual, directed at children; a guide on non-hormonal contraceptives; a guide about the human papilloma virus; and Pillow Manual, a sexual education guide. Dr. Fernandez, in particular, gives many talks and participates on radio shows, where the public can phone in. In 2003, 22 women and 12 men work in the Costa Rican Sexologist Institute. There are about 50 staff people working on different projects. They assist between two and 300 clients each month, and up to about 150 clients are attended to each month by staff sexologists, gynecologists, psychologists, or lawyers. Other sexologists, including some women, have private practices.
References and Suggested Readings
Biezans, M. H., R. Biesanz, & D. Z. Biesanz. 1999. The Ticos. Culture and social change in Costa Rica. Boulder, CO, USA: Lynne Rienner Publishers.
Brenes, I. 1994. Actitudes y prácticas del aborto inducido en Costa Rica [Attitudes and practice of induced abortions in Costa Rica] (Thesis for postgraduate degree in statistics). University of Costa Rica.
CIA. 2002 (January). The world factbook 2002. Washington, DC: Central Intelligence Agency. Available: http://www.cia.gov/cia/publications/factbook/index.html
Campos Guadamuz, A., & J. M. Salas Calvo, eds. 2002. Masculinidades en Centro América [Masculinities in Central America], San José, CR: WEM & FIG/ACDI.
Claramunt, M. C., 1999. Sexual exploitation in Costa Rica: Analysis of the critical path to prostitution for boys, girls and adolescents. UNICEF, Costa Rica.
Faerron, A. L. 2002. La educación para la sexualidad en el contexto de la sociedad Costarricense: Análisis del proceso de diseño y gestión del Programa Amor Joven (1998-2001) [Sexual education in the Costa Rican context: Analysis of the design and execution of the Young Love Program (1998-2001)] (Thesis for postgraduate degree in the Women’s Studies Program). University of Costa Rica.
Madrigal Pana, J. 1998. El vaivén de un cabezal. Un estudio sobre los traileros en América Central y su relación con el Sida. San José, CR: Editorial Ilpes.
Miller, T. C. 2003 (March 24). Raped, pregnant and only 9, her abortion divides Nicaragua. Los Angeles Times; Newark [New Jersey] Star-Ledger, p. 18.
Ortiz Gutiérrez, J. 1996. Las 100 preguntas y el arco iris del género [100 questions and the gender rainbow]. San Pedro, CR: Fundación Gaia.
Preinfalk Fernandez, M. L., 1998. Vivencias y practicas sexuales de las mujeres jóvenes residentes en Rincón Grande de Pavas [Sexual experiences and practices of young female residents of Rincón Grande of Pavas] (Thesis for postgraduate degree in Women’s Studies). University of Costa Rica and National University, Costa Rica
Schifter, J. 1997/1998. La casa de Lila. Un estudio de la prostitución masculina, San José, CR: Editorial Ilpes, 1997. (Published in English: Lila’s house. Male prostitution in Latin America. New York: Haworth Press, 1998.
Schifter, J., 1999/2000. Caperucita Rosa y el lobo Feroz. Sexo público Latino. San José, CR: Editorial Ilpes, 1999. (Published in English: Public sex in a Latin society. New York: Haworth Hispanic/Latino Press, 2000.
Schifter Sikora, J., & J. Madrigal Pana. 1996/1997. Las gavetas sexuales del Costarricense y el riesgo de infección con el VIH [The sexual compartments of the Costa Ricans and the risk of HIV infection]. San José, CR: Imediex, 1996. (Published in English: The sexual construction of Latino youth: Implications for the spread of HIV/AIDS. New York: Haworth Press, 1997.
Schifter Sikora, J., & J. Madrigal. 1997. Ojos que no ven . . . Psiquiatría y homofobia. San José, CR: Editorial Ilpes. (Published in English: Eyes that do not see: Psychiatry and homophobia. New York: Haworth Press.
Serrano Madrigal, E. 2002. De la memoria individual a la historia social. Grupos de encuentro de las mujeres lesbianas Costarricenses [From individual to social history. Costa Rican lesbian women’s groups] (Thesis for postgraduate degree in Women’s Studies), University of Costa Rica—National University, Costa Rica.
UNAIDS. 2002. Epidemiological fact sheets by country. Geneva, Switzerland: Joint United Nations Programme on HIV/AIDS (UNAIDS/WHO). Available: http://www.unaids.org/hivaidsinfo/statistics/ fact_sheets/index_en.htm.