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“The only thing necessary for these diseases to the triumph is for good people and governments to do nothing.”

    

 

RURAL SEXUAL BEHAVIOUR IN INDIA

Background

The spread of the HIV/AIDS epidemic in India, driven primarily by sexual contact, has impelled research into sexuality and sexual behavior in various sectors of the Indian population. The decade of the nineties saw numerous studies of sexual behavior in a variety of locations, mostly characterized by a strong focus on qualitative methodology, exploring in-depth the complex patterns and contexts of sexual behavior. However, there has been more research in urban areas, with insufficient attention to rural situations and tribal sexual behavior.

The various aspects of HIV/AIDS have been studied primarily against the backdrop of risky behavior, with studies focused on truckers, commercial sex workers (CSWs), the gay-lesbian community, intravenous drug users (IDUs) and students, among others. Recent evidence shows that the HIV/AIDS epidemic in India has now moved into the general population. Current estimates indicate that there are about four million Indians living with the virus (making it the country with the largest estimated number of HIV positive people in the world), with the epidemic growing rapidly. The spread of HIV infections in the general population means that research about sexual contacts and behaviors cannot be focused only on so-called “high-risk” groups. Rather, the sexual relations and patterns in all sectors of the Indian populationľincluding the full range of socially, culturally, and demographically diverse groupsľmust be studied, a need that cannot be sufficiently emphasized.

Study Objectives

The present study was undertaken to understand sexual behavior patterns among the rural population, and also to describe various causative and contextual factors for varying patterns of sexual behavior among different age-groups of rural women and men.

It investigated a broad range of behaviors associated with romantic, emotional and erotic interests involving individuals and their relations with other persons, both same sex and opposite sex. The study understands sexuality to mean the full range of sexual behaviors as they are manifested in the life of an individual, within the context of family, village life, social relationships and health.

From the broad range of issues it addresses, the study attempts to answer the following questions:

·        What is the pattern of different sexual behaviors among the sample population? For example, what is the pattern of pre-marital and extra-marital relations, homosexual behavior, sexual relations within the family (incest), sexual relations across different age groups and/or any other form of sexual behavior?

·        How is sexuality and sexual behavior expressed in rural areas? What are the associated connotations and language? What, if any, are the gender issues involved in sexual behavior?

·        What are the cultural (i.e., beliefs, attitudes, power structures and other related norms) and contextual factors (i.e., available sex, loneliness, influence of media, economic situation, force, and/or group behavior, among others) that give rise to these behaviors and sustain them?

·        How vulnerable are adolescent girls, boys, and men and women to sexually transmitting infections by way of their exposure to sexual behavior and experience of sexual violence?

·        What is the extent of HIV/AIDS awareness among the study population?

·        What is the relationship between sexual attitudes and myths about sexuality and sexual health and sexual behavior?

Study Methodology

Sampling design: The study was carried out in two phases. Focused ethnographic work was carried out in the first phase, followed by a representative household survey of 2,910 men between 18 and 40 years, thus combining both qualitative and quantitative approaches.

Both phases of data gathering were undertaken in five Indian statesľHaryana, Rajasthan, Uttar Pradesh, Orissa and Karnatakaľcovering one district in each state. The qualitative phase of the study was conducted in 10 rural sites of the selected states, with 165 men and 85 women included in the study, while the quantitative phase covered 50 villages where only men were interviewed.

The states were selected randomly, as being representative of the eastern, western, northern, southern and central regions of India and were chosen from the list of states that had more than 80 percent rural population.

DistrictsľMahendragarh district, Haryana; Jalore district, Rajasthan; Jaunpur district, Uttar Pradesh; Puri district, Orissa; and Tumkur district, Karnatakaľwere also chosen randomly, but only from a list that fulfilled the following criteria, having:

·        More than 80 percent rural population (1991 Census); and

·        Less than 5 percent tribal population.

Method: The focused ethnographic study comprised two stagesľ

·        Interviews for special case studies with a total of 197 persons (133 males and 64 females) belonging to diverse socio-economic backgrounds and sexually active at the time of survey; and

·        Interviews with 53 key informants, comprising 32 men and 21 women, individuals who were specially outgoing and willing to talk and seemed to possess a special body of information about cultural and environmental factors related to the village and all the domains and sub-domains presented in the conceptual framework.

This study was conducted in two sites in each of the selected districts, making a total of ten villages. The selected sites fulfilled three specific criteria:

·        Villages that had less than 5 per cent tribal population;

·        Villages that had a population size of more than 500, and

·        Villages that were at least 5 kms away from the nearest town or any urban center.

Quantitative and qualitative surveys: The expected sample in the quantitative survey for each was around 600 men. However, due to non-response/non-availability of some of the selected households, the actual sample size covered ranges between 570 men in Haryana and Karnataka, 590 men in Orissa, 579 men in Uttar Pradesh, and 601 men in Rajasthan. As illustrated by their background characteristics, the selected men represented a variety of ethnic, socio-economic and demographic characteristics thought to be typical of rural India.

The first step in the qualitative data collection phase involved researchers meeting both formal and informal gatekeepers in the villages. They introduced the organizations (IIPS, Government of India, Ministry of Health and Family Welfare and UNFPA) conducting the research and its purpose, which was articulated in terms of the broad health needs of both men and women. Gatekeepers were informed about the sensitive nature of data and assured of complete confidentiality. Researchers were oriented to deal with questions, concerns, and clarifications, discuss benefits and also discuss the main issues in the village, which involved:

·        Making contact and establishing a rapport with individuals in the community.

·        Getting information about the general layout of the community, locations of health providers and other facilities, and other useful general data concerning social groups, divisions, special features, and other information.

·        Identifying individuals (in the group) who were later approached as key informants.

·        Observing public settings such as “lovers’ lanes”, youth “hangouts”, bars and similar places as well as settings such as community centers, women’s gatherings, markets and ceremonies.

    

The qualitative data was collected through free-lists, pile sorts and in-depth interviews seeking histories and current sexual activities. Sexuality and sexual behavior was considered from the perspective of associations with romantic, emotional and erotic interests as well as sexually intimate behavior of individuals and their relations with other persons, both same sex and opposite sex. Sexuality was taken to mean the full range of sexual behaviors as they are manifested in the life of the individual within the context of family, village life, social relationships and health.

A brief overview of the selected sites: The five rural districts selected for the study, while they share many common features, including low to very low female literacy, and the easy availability of pornographic material and films, represent the varying landscape of rural India.

Jaunpur district in eastern Uttar Pradesh, is well known for its high emigration, with a significant proportion of its male population working in Mumbai. The survey found some villages with virtually no adult men; all are reportedly employed in Mumbai, while women and family elders manage the households and the fields. With a rural population of about 3.6 million, rural Jaunpur has a female literacy rate of about 17 percent. Early marriage is widely prevalent as also a system called ‘gauna’, whereby the consummation of marriage takes place after a gap of about 3-5 years.

Puri district in Orissa is famous for the ancient Hindu temple of Jagannath and thus attracts a large number of tourists through the year. The rural population of about 1.2 million is particularly adversely affected due to the periodic devastating cyclones. Rural female literacy is about 29 percent. 

Jalore district, located in western Rajasthan, has a scattered rural population of about 1.3 million. Famed for its several ancient monuments, it also has a rich heritage in artisanship, including diamond cutting. A large number of skilled diamond cutters from the district migrate seasonally to work either in Mumbai or northern Karnataka, taking the men away from home for a substantial part of the year, leaving the household and fields in the hands of women and elders. While rural female literacy is only about 10 percent, in-depth interviews revealed that certain rural communities here practice commercial sex in a non-commercial context, i.e., in households where hospitality includes offering guests sexual favors. Yet another common practice is marriage on an ‘exchange’ basis (locally termed as ‘atta-satta’) whereby a brother-sister pair cross-marry another brother and sister pair. This puts several young men who do not have sisters at a disadvantage and affects their eligibility for marriage.

Mahendragarh district in Haryana has a rural population of about 0.7 million, with female literacy at about 22 percent. Relatively advanced economically, Haryana is also known for very high female feticide rates and an adverse sex ratio unfavorable to females.

Tumkur district in Karnataka, close to the state capital Bangalore and relatively developed, has an approximate 2 million rural population with about 23 percent female literacy. The principal industries in the district are manufacture of coarse cotton cloths, woolen blankets and ropes. Tumkur also has a large number of private colleges with students from all over the state and other parts of India. The practice of Kudike (where a widow remarries but does not get the rights or ‘position’ of wife) is prevalent.

The study found that in all the rural sites, except those in Rajasthan, pornographic movies and literature were popular. In remote areas of eastern Uttar Pradesh (UP) and in Karnataka, sexually explicit posters of pornographic films are commonly displayed. The researchers’ observations were that the audience for porn films is made up mainly of young college boys and middle-aged persons.

Study Findings

Socio-demographic profile

State-wise coverage of the number of respondents, giving some important characteristics, are highlighted below (Table 1).

Table 1: Select Characteristics of Respondents by State

 

Selected Characteristics of respondents

State*

Haryana

Karnataka

Orissa

Rajasthan

Uttar Pradesh

Total

Number of respondents

  570  

570

590

601

579

2910

Ever attended school

526 (92.3)

463 (81.2)

535 (90.7)

309 (51.4)

451 (77.9)

2284 (78.5)

Currently unmarried

79 (13.9)

154 (27.0)

173 (29.3)

130 (21.6)

23 (4.0)

559 (19.2)

Age below 25 years

Mean age (year)

238 (41.8)

     26.7

126 (22.1)

     30.1

162 (27.5)

     29.3

181 (30.1)

     28.6

135 (23.3)

     28.5

842 (28.9)

       28.6

Currently employed

485 (85.1)

505 (88.6)

501 (84.9)

570 (94.8)

386 (66.7)

2447 (84.1)

Hindu

564 (98.9)

519 (91.9)

586 (99.3)

554 (92.2)

530 (91.5)

2753 (94.6)

Scheduled caste

Scheduled tribe

OB caste

General

  112

    3

  294

  151

 123

  20

 201

 187

  178

    2

  252

  150

  195

   39

  246

  116

  171

    2

  358

   46

779 (26.8)

    66 (2.3)  

1351 (46.4)

650 (22.3)

The average age of the respondents was 29 years (from 27 years in Haryana to 30 years in Karnataka). In terms of educational level, most of the respondents (78.5 percent) had attended school, except in Rajasthan, where about an equal number had attended as had not attended school. The marital status of respondents varied widely among the five states under study. It may be appropriate to mention here that early marriage continues to be the norm in northern India.

Sexual behavior (including pre- and extra-marital sexual behavior)

Overall, 90 percent of all the men interviewed (aged 18-40 years) reported having experienced sexual intercourse (Figure 1). Exposure to sexual intercourse, on an average, seems to be very closely associated with age at marriage. This becomes clearer from the data on the incidence of pre-marital sex. On an all-India level, eight percent of the men had experienced sexual intercourse prior to the age of 15. The proportion varied state-wise, from a low of 1.6 percent in Karnataka, a state with a relatively higher age at marriage, to 16.4 percent in Uttar Pradesh, a state where early marriage is relatively more common.

Overall, a little over one-fourth of the married men reported having had sexual intercourse before marriage. About one-third of the men reported having had sex between the wedding and the actual consummation of marriage, indicative of higher sexual activity between marriage and consummation of marriage especially in UP and Haryana, where the custom of ‘gauna’[1] exists. These findings are significant as generally it is believed that marital sexual activity starts only after gauna heralding consummation of marriage. In Uttar Pradesh, the proportion having had pre-marital sex moves up from 25.7 percent for those who experienced it before marriage to 47.3 percent for those who had a sexual experience after the wedding but before consummation. In Karnataka and Orissa, where the system of ‘gauna’ is non-existent, there is no difference between the two measures of pre-marital sex for currently married men.

Two indices of sexual intercourse were measured for unmarried menľone, ‘ever’ having had a sexual experience and, two, sex ‘during the past 12 months’. Overall, about 43 percent of the unmarried men in the study population reported having ever experienced sexual intercourse. Overall, across the five states, one-third reported being actively involved in sexual activities over the immediately preceding 12 months, the highest (48 percent) in Orissa and the lowest (16 percent) in Karnataka (Figure 2).

The study found one-fifth of all the currently married men in the sample as having ever had sexual intercourse with persons other than their spouses. A total of 15 percent of the currently married men reported having had extra-marital sex in the immediately preceding 12 months (Figure 3). The percentage however varied from a low of 6.3 in Uttar Pradesh to 37.4 in Orissa.

A much larger proportion of currently married men in Orissa, as compared to men from other states, reported having experienced extra-marital sex, both ‘ever’ (over 38 percent) as well as in the past 12 months (a little over 37 percent). This relatively high prevalence of extra-marital sex in Orissa is consistent with the findings on pre-marital sex. Although Puri may not truly represent the rural scenario of all of Orissa, the high prevalence of both pre-marital and extra-marital sex suggests the need to have focused educational programs in Puri district. What is surprising, however, is that in UP, where a very high proportion of married men reported pre-marital sex, only a small minority reported current extra-marital sexual encounters. Given the fact that a very high proportion of men in this part of UP work in distant places like Mumbai, which keeps them away from home for longer duration, one would expect a higher prevalence of extra-marital sex. Under-reporting of current extra-marital sex by the married men in the UP sample cannot be ruled out. However, an alternative explanation could be that most men in the sample were those living with their families, unlike seasonal or other migrants, and hence had less opportunity for extra-marital sex.

Sexual partners

Data on different types of sexual partners in the past 12 months for both married and unmarried respondents revealed some interesting trends (Figure 4). The study defined sexual partners, besides spouses for married men, in terms of four broad categories and left it to the respondents to define their partners in one of the given categoriesľ

·        Regular non-commercial;

·        Casual;

·        Commercial female sex worker; and

·        Men.

Besides spouse, the most usual extra-marital sexual experience for married men in rural areas with a “casual” female partner followed by “regular non-commercial,” and for unmarried men is it is “regular non-commercial” followed by other “male” partner.

    

Men defined ‘casual’ sexual partners as people with whom they had no emotional relationship. Usually, these involved one-time encounters. A casual sexual partner could be a known person within the family, a friend or, as happened very often, a stranger or relatively unknown person. Among known persons, a casual sexual partner was usually a woman who the respondent had met at a religious or family function and coerced into having sex. Young men were found to look for ‘prey’ on these occasions and consciously plan a strategy to have casual sex. Unmarried men described a number of occasions when they forced a partner (generally a woman) into sex, who they happened to meet at religious or family functions or while travelling. Very often, however, the men portrayed the woman as having seduced him and initiated the sexual activity.

It is interesting to note that most of the men described these one-time casual sexual encounters as non-risky (“isme khatra nahi”) and non-commercial. In some cases, casual sex with an unknown woman was also seen as non-risky because the woman performed oral sex followed by vaginal sex and charged no money. There was no way to ascertain whether the sexual partner in these such encounters was a commercial sex-worker or not.

The description of regular non-commercial sexual partners, on the other hand, always involved a known person with whom the sexual encounter happened more than once. The partners included a friend’s wife or sister, a wife’s sister, or a sister-in-law within the family. Men described these relationships as primarily ‘emotional’, which initially happened ‘spontaneously’ (“achanak ho gaya”) and was then sustained. These regular non-commercial sexual relationships were described as quite ‘confidential’ and in the opinions of respondents “nobody knew about it”. In fact, in most cases married men described a very close relationship between the ‘other woman’ and the wife. None of the men saw any risk in having unprotected (without condom) sex with the regular non-commercial partner.

It may be noted that for both married men as well as unmarried men, sex with sex workers is not as common as it is with other male partners. Close to 10 percent of unmarried men and 3 percent of married men reported having had sexual intercourse with other men in the past 12 months. The unmarried men described sexual acts, which included mutual male-to-male masturbation and anal sex.

State-wise distribution of extra-marital sexual partners in the past 12 months for the currently married men revealed a wide variation (Table 2). A larger proportion of men in Orissa reported to have had extra-marital sex with ‘casual partners’, ‘regular non-commercial partners’, and ‘men’ as compared to the men from other states. Reporting of sex workers as sexual partner was uniformly low in all the states.

Table 2: State-wise distribution of currently married men reporting different types of extra-marital sexual partners in the past 12 months (percentages)

 

Sexual partners

States

All States

(2351)

Haryana

(491)

Karnataka

(416)

Orissa

(417)

Rajasthan

(471)

UP

(556)

Regular non-commercial

 

Casual

 

Sex worker

 

Male

3.7

 

10.2

 

4.1

 

2.6

3.6

 

4.1

 

1.0

 

---

16.3

 

21.9

 

3.4

 

9.3

4.7

 

3.6

 

2.0

 

2.8

1.4

 

2.7

 

1.7

 

1.3

5.6

 

8.1

 

2.3

 

3.1

Five percent of all the men interviewed reported to have had sexual intercourse with more than one type of partner in the past one year, ranging from one percent in UP to 14 percent in Orissa, which also reported a high level of non-marital sex among all men. Orissa, thus, not only has a higher proportion of men engaged in pre-marital and extra-marital sex, but also engagement with multiple partners (Figure 5). The most usual extra-marital sexual experience for married men in rural areas was found to be with a “casual” female partner followed by “regular non-commercial” partner. For unmarried men it was found that a “regular non-commercial” partner was most common, followed by the option of a “male” partner.

Condom use

The study found that the high risk inherent in such behavior was compounded by the low use of condoms in all the states (Figures 6 and 7).

Overall, however, condom use was found to be much higher among unmarried respondents than the married men. Close to one-fourth of the unmarried men compared to only one in ten among married men reportedly used condoms with regular non-commercial sexual partners. One in every five and one in every three unmarried man used condoms if they had sex with casual and non-commercial partners and sex workers respectively. No condom use was reported in male-to-male sex (Table 3).

Table 3: Condom Use in Current Sexual Encounters by Type of Partner: All-India

 

Type of partner:

Unmarried

(N=559)

Currently married (N=2351)

Total

(N=2910)

Percentage:

N:

Percentage:

N:

Percentage:

N:

Spouse

- (-)

--

9.7 (226)

2326

9.7 (226)

2326

Regular Non-Commercial

23.0 (20)

87

11.5 (15)

131

16.1 (35)

218

Casual

20.5 (15)

73

5.3 (10)

190

9.5 (25)

263

Commercial Sex Worker

30.8 (8)

26

38.2 (21)

55

35.8 (29)

81

Male Partner

0 (0)

53

0 (0)

72

0 (-)

125

 

Data depicted in the table reflects the fact that both married and unmarried men reported very low levels of condoms use in both casual and commercial sex.

It must be remembered however, that state-wise data on condom use with different sexual partners presented in this study needs to be interpreted cautiously due to the very small numbers of men reporting these behaviors. As a possible trend however, the given data suggests that condom usage is relatively higher with sex workers in all the states under study, than with ‘regular non-commercial’ or ‘casual sexual partners’. The low usage of condoms with casual partners presents potential HIV/AIDS risk and is a matter of extreme concern.

STI/HIV/AIDS awareness

All the men in the sample were asked whether, in the past year, they had suffered from any of a given list of seven symptoms of sexual dysfunction. These included early ejaculation, lack of penile erection, thinning of semen, wet dreams, involuntary loss of semen, loss of sexual desire and ‘kamjori’. Little over half of them (55.1 percent) reported to have suffered from at least one of these sexual health concerns (Figure 8).

In view of the established relationship between sexual health anxieties, risky sexual behavior and STIs, it is important to take note of these anxieties in HIV/AIDS prevention programs.

The predominance of male sexual health concerns have been pointed out by quite a few recent studies of India. For example, a study in Mumbai showed a prevalence of 45 percent non-contact problems among men (Verma et al 1999). The most frequently mentioned sexual health concerns in Orissa were semen secretion or “thinning of semen”, severe itching in the genital area, nocturnal emission, AIDS and gonorrhoea (AIMS Research, 1997; Collumbien et al 1999). Similarly in Mumbai, men reported semen loss concerns in various forms (Verma et al 1999). All these studies suggest that STI symptoms and AIDS do not appear as the most prominent sexual health concerns for Indian men. These findings have important lessons for the public health system, which intends to address the issue of STI and HIV/AIDS prevention. The presence of non-contact problems has been shown to be closely linked with STIs, risk behavior antecedents (Verma and Schensul, 2002).

Only 71 percent of the respondents in this sample study had heard of a disease that can be transmitted through sexual intercourse, with a low of only 41 in Rajasthan (Figure 9).

The men in the sample listed five possible types of STIsľgenital discharge, burning sensation/pain on urination, genital ulcers/sores, anal ulcers/sores, and swelling in the groin. Over 27 percent reported to have ever had experienced genital discharge, while 11 percent reported having experienced this in the past 12 months. The numbers were highest among men from Orissa. A majority (66 percent) thought the discharge was actually semen and not pus, again indicating semen loss anxiety and a further possible indication of risky sexual behavior. What was also of interest was that despite defining the discharge as semen, less than 17 percent of the men were found to have sought any treatment, most (11.5 percent) from private unqualified practitioners. About eight percent were trying out home remedies.

Five percent of all men reported having experienced genital ulcers and soresľwhich are more clear indicators of STIsľduring the past 12 months. A high proportion of these men did not seek treatment. Only seven percent reported having sought treatment from government doctors or dispensaries. The presence of STIs is closely associated with HIV infection and many of these men might be themselves HIV positive and also may perhaps transmit the virus to their partners.

About 87 percent overall reported having heard about HIV/AIDS, from a low of 70 percent in Rajasthan to a high of 97 percent in UP. One in ten thought that HIV/AIDS is curable.

Only about 47 percent of the men said that the condom is an effective means of preventing HIV/AIDS/STIs. The reporting from UP in particular indicates that people may have heard of HIV/AIDS but this does not necessarily mean that they know also about the crucial aspects of its prevention. A large proportion of men are unlikely to use condoms during risky sexual intercourse, as they seem to either believe that the condom would not be a helpful protection against HIV or they are ignorant about this.

Table 4: Overall awareness levels about aspects of HIV/AIDS among

 rural men by state

 

 

States (all figures in percentage)

Haryana

Karnataka

Orissa

Rajasthan

Uttar Pradesh

Total

Ever heard about HIV/AIDS

90.7

90.0

87.3

70.2

96.9

86.9

HIV/AIDS is curable

8.6

9.6

11.9

5.5

10.0

9.1

Condom prevents HIV/AIDS

59.8

67.5

31.2

41.3

33.9

46.5

Knows someone affected by it

6.0

34.6

20.5

22.0

16.4

19.9

Knows someone died of AIDS

4.9

38.4

16.8

17.0

32.1

21.8

While about 20 percent of the men reported knowing someone who is affected by HIV/AIDS in their area, it is not clear how they learnt about the HIV status of other individuals. This ‘knowledge’ may have serious negative implications in terms of stigma and discrimination.

A large number of men were found to consider female sex workers as potential carriers of HIV/AIDS (50 percent). It is interesting to note that male sex workers were not seen to be as risky as female sex workers. In fact male sexual partners were seen as risky transmitters only by about one-fifth of the men. In UP, sexual partners other than the spouse were seen as potential transmitters by a fairly large number of the respondents.

Table 5: Risk perceptions of HIV/AIDS transmission from different sexual partners by state

 

Can get HIV/AIDS and STDs from type of sexual partners

States (all figures in percentage)

Haryana

Karnataka

Orissa

Rajasthan

Uttar Pradesh

Total

Spouse

20.5

0.4

2.0

10.6

11.1

8.9

Regular female

48.6

0.4

1.4

29.3