This study is the first to examine the psychometric properties and factor structure of the sexual empowerment sub-scale of the WGE-SRH Index across ten culturally diverse settings. Overall, results suggest the scale is a reliable tool for understanding how women frame and act on sexual decisions across diverse cultures in sub-Saharan Africa. After dropping two items, psychometric properties were strong in most sites, except Rajasthan, India, where item fit remained slightly below desired thresholds.
Findings confirm a two-factor structure of sexual empowerment (existence of choice and exercise of choice), similar to that originally identified by Moreau and colleagues [17]. Notably, however, some items performed differently across contexts. In Rajasthan, India, in particular, full models showed that the item,“If I show my husband/partner that I want to have sex, he may consider me promiscuous” loaded strongly onto the existence of choice domain, while the item, “If I do not want to have sex, I am capable of avoiding it with my husband/partner” loaded strongly onto exercise of choice. In contrast, factor loadings for these two items showed considerable variability in sub-Saharan African settings, with the promiscuity item underperforming in the majority of contexts. Similarly, the “avoid” item did not meet desired thresholds in several sites. As such, both items were dropped from final models to ensure consistency across sub-Saharan African sites, however, these items may still have relevance and be considered as critical aspects of sexual empowerment within the context of research in Asia, where commonality of extramarital relationships and implications of promiscuity may differ [32,33]. Combining the sexual existence of choice and sexual exercise of choice domains into a single measure resulted in a multidimensional index of sexual empowerment with moderate to good internal reliability (alpha range 0.59 in Kongo Central, DRC to 0.69 in Niger), along with evidence of goodness of fit across sites, withstanding Rajasthan, India.
Understanding cross-site differences in existence vs. exercise of choice is relevant for the implementation of interventions and programs seeking to counteract harmful gender norms. Marked variations were seen across sites in women’s perceptions of their partners’ responses to refusing sex, as well as their own confidence in voicing when and when not to have sex. Niger, specifically, stood out as a site with overall low exercise of choice; however, this setting was comparable to other sites for existence of choice items. Such contrast between existence and exercise of choice may be indicative of where a population lies on the empowerment pathway [15]. Of note, Niger has the highest prevalence of child marriage globally [27]. While many contexts have overcome gender and power barriers related to existence of choice surrounding sex, many women still may not feel comfortable exercising this choice. In such contexts, programs and interventions should focus on supporting women’s ability to communicate and negotiate their sexual choices, rather than normative factors prohibiting women’s sexual needs in the first place. Community dialogues, such as those implemented for intimate partner violence, may be useful to support communication and negotiation, while concurrently working with men and the broader community [34,35,36]. As opposed to contraceptive empowerment, where women can exercise their choice to use contraception via covert contraceptive use without first having the existence of choice [30,37], sex requires an interaction between sexual partners and, therefore, both existence and exercise of choice must co-exist for women to achieve volitional sex. These results point to the importance of disentangling the domains of existence vs. exercise of choice for sexual empowerment.
Identifying within-site variation is also necessary to determine where empowerment interventions are needed or may have fallen short. Some items were particularly polarizing within contexts—specifically, the “promiscuous” item had the majority responses concentrating in strongly agree or strongly disagree categories, with few women indicating neutral empowerment (i.e., neither agreeing nor disagreeing). These polarized responses persisted for exercise of choice items across contexts and were particularly pronounced for items focusing on women’s desire to have sex rather than not to have sex. Such results highlight the sexual double standards between men and women reported in previous studies [15,38,39,40] and speak to the undervaluing of women’s sexual pleasure as a key component of their sexual health [41].
These cross-cultural findings further elucidate that sexual empowerment is largely constrained—when examining our overall sexual empowerment scores, less than half of the sites reported the majority of women with high or highest empowerment scores (Lagos, Nigeria: 74.5%, Kenya: 58.4%, Kinshasa, DRC: 57.7%, and Rajasthan, India: 54.7%). In sites where existence and exercise of choice were in opposition (i.e., Niger, Kano, Nigeria, and Kongo Central, DRC), overall empowerment concentrated in the neutral category. Notably, these lower empowerment sites likely represent different stages of gender norms programs (i.e., focus on existence of choice rather than exercise of choice) and should continue to be examined.
This study has several strengths, including distinguishing between sexual existence and exercise of choice and its use of ten population-based samples to validate a sexual empowerment sub-scale and compare sexual empowerment levels across sites. Nonetheless, findings should be considered in light of some limitations. Specifically, item wording pertains to a woman’s current husband/partner, precluding understanding of how these items apply within concurrent partner relationships. Women may feel empowered sexually with some partners, but not with others. Within-site variation in sexual empowerment was not examined to afford fuller exploration of sexual empowerment across populations, however, given cultural heterogeneity in practices within many study sites, this should be examined in future studies. Reasons for sexual empowerment within and across sites, as well as an understanding of who is empowered, as additionally needed. Lastly, it is noted that only one small site within Asia was included in this study (Rajasthan, India) and is not generalizable to the whole of Asia nor the whole of India.