Pattern of sexual behavior in adolescents and young adults attending STD clinic in a tertiary care center in South India.

BACKGROUND AND OBJECTIVES: There is an alarming increase in the prevalence of sexually transmitted infections (STIs) among adolescents and young adults of our country. The aim of our study is to depict the current pattern of sexual behavior in this vulnerable sector of population.
MATERIALS AND METHODS: The study was performed by reviewing the medical records of 1140 adolescents and young adults from January 2015 to June 2015. Demographic and sexual behavior data were collected in a predesigned format. The outcome variables such as age of coital debut, sexual promiscuity, and knowledge about condom usage were statistically analyzed among the study population.
RESULTS: The male: female ratio was 1.6:1. Nearly 78.2% were unmarried and 60% have completed their high school level education. Mean age of coital debut was 21.1 years in males and 18.6 years in females and 201 (17.6%) were practicing risky sexual behavior. Homosexuality was observed in 109 (33.4%) men. Furthermore, 149 (13.1%) had exposure to commercial sex workers. Prevalence of STIs was 99 (8.7%). The overall condom usage at least once was reported only by eighty (23.5%) adolescents. Complete knowledge about condom usage was found to be very low (8%).
CONCLUSION: Our study reports a high incidence of risky sexual behavior as well as a lack of complete knowledge about safe sex practices in the study population. The need of the hour is to implement sex education program at high school level to prevent STIs in this vulnerable population.

INTRODUCTION

Multiple factors are known to determine the sexual behavior of an individual.[1] Most of them are rooted in early adolescent age, thus mandating proper nurturing of them at formative stage itself. World health organization defines adolescent and young adults as individuals between 10 and 24 years of age.[12] More than 1.75 billion of the world's population belongs to 10–24 years of age, making every fifth person in the world an adolescent.[3] In India, the population aged between 10–24 years accounts for 373 million (30.9%) of 1210 million of nations' population with every third person in our country belonging to this age group.[4] Furthermore, they contribute to 31% of the country's human immunodeficiency virus disease (HIV) burden.[5] The aim of our study is to depict the current pattern of sexual behavior in adolescent and young adults, the influence of social and demographic factors, and the possible solutions to reduce the risk of sexually transmitted infections (STI)/HIV infection.

MATERIALS AND METHODS

The study was conducted between the period of January 2015 and June 2015 in a retrospective manner by review of hospital records. A total of 1140 adolescents and young adults in the age group of 10–24 years who attended the outpatient clinic of the Institute of Venereology during the entire study period were enrolled as the study population. The majority of the study participants were referred by other departments for risk assessment while rest of the patients were either self-reporting or referred by nongovernmental organizations (NGOs). The detailed socioeconomic and sexual behavioral data including the age of coital debut, sexual promiscuity, orientation toward partner, frequency and knowledge about condom usage, and present or past history of STIs were collected in a predesigned format.

The study participants were categorized into three groups: group 1 belonging to 10–14 years, Group 2: 15–19 years, and Group 3: between 20 and 24 years of age. The purpose of this subgrouping was to enable a comprehensive evaluation of the various risk factors in the different age groups, which would enable us to determine the stage at which interventions could be implemented. The outcome variables that were evaluated among the study population included the age of coital debut, sexual promiscuity, and knowledge about condom usage.

The statistical analysis was performed using SPSS Statistics version 21.0 (IBM). The statistical association among the outcome variables was obtained using Chi-square test and Fisher's exact test.

RESULTS

The adolescent and young adults constituted 16.6% of the total outpatient strength during our study period. Out of 1140 patients included in the study, 700 (61.4%) were males and 440 (38.6%) were females. The male:female ratio was 1.6:1. Among the study population, 11 belonged to Group 1, 236 (20.7%) to Group 2, and 893 (78.3%) to Group 3. In our study participants, 78.2% were unmarried and 21.3% were married with a female predominance (P < 0.001). Around 60% of study group had completed high school education. The illiteracy level was found to be higher in females [Table 1]. With respect to professional status, 317 (27.8%) of the study participants belonged to the salaried service sector which constituted the majority, followed by students 256 (22.5%), homemakers 149 (13.1%), and unemployed 111 (9.7%) [Figure 1].

Table 1

Sociodemographic characteristics of patients attending sexually transmitted diseases clinic

Figure 1

Distribution of participants on the basis of occupation

With regard to sexual behavior, 326 (46.5%) males and 212 (53%) females were involved in sexual activity at least once, with majority of them 499 (55.9%) belonging to Group 3 (P < 0.005). Mean age of coital debut was 21.1 years in males and 18.6 years in females. It was significantly lower in women (<18 years in 54 [78.3%]) when compared with men (<18 years in 15 [21.7%] P < 0.001). Most of the females in the study population had their coital debut under 19 years of age, and most men had their coital debut after 20 years of age [Figure 2].

Figure 2

Age of coital debut in men and women

In our study group, 201 (17.6%) were practicing high-risk sexual behavior by patronizing casual and multiple partners. In this subset, the percentage of males was more than females (P < 0.001). The trend toward homosexuality was noticed in 109 (33.4%) of men and 72% of MSM were promiscuous. Moreover, half of them were indulging in only homosexual activities, and the other half indulged in bisexual acts. Furthermore, 149 (13.1%) had exposure to a commercial sex worker. In Group 3, 97 (10.9%) had a better knowledge about condom usage when compared to Group 1 (0%) and Group 2 (4 [1.7%]) with P < 0.001 [Figure 3]. In those who had complete knowledge about condom usage, males outnumbered females [Figure 4]. The prevalence of STIs was reported in 8.7% of the study participants. The risk factors for STI included poor condom knowledge and sexual promiscuity (P < 0.001). Although the overall usage of condom at least once in the past 6 months was reported by eighty (23.5%) of the study participants, none of the study participants reported the consistent use of condom.

Figure 3

Comparison of knowledge about condom usage among three groups of study population

Figure 4

Complete knowledge about condom usage in men and women

DISCUSSION

Adolescence is a phase of experimentation and least attention is given to the sexual needs and queries of this population. The physical, biological, and psychological factors make this group more prone to acquiring sexually transmitted diseases than adults.[6] To add to this, the uncontrolled exposure to media, lack of access to correct information, and an environment which makes discussing issues around sexuality with elders, a taboo adds to their vulnerability.

National Aids Control Organization (NACO) has recommended adolescents and young people the following “ABC approach” in their sexual behavior.[5]

A - Abstinence: Delay in sexual debut

B - Being faithful to partner; sharing a mutually monogamous relationship

C - Correct and consistent use of condom, complete knowledge of their three-fold protection from HIV, other STIs, and unwanted pregnancy.

In our study, we have tried to analyze the status of the above parameters in our participants. Mean age of coital debut in our study was 21.4 years in males and 18.6 years in females, which is in consistent with a Kolkata-based study by Taraphdar et al.[7] and with that of Behavioural Surveillance Survey NACO 2006.[8]

In our study, it was found that under 18 years of age, 78.3% of females had coital initiation as compared to 21.7% in males. Similar observations have been reported by Taraphdar et al., Jayasree et al.,[9] and Olasod.[10] This lower age of coital debut in females is attributed to the high proportion of married females (78.2%) in our study group. Taraphdar et al. also report that the reason for lower age of coital debut in females in our country is probably due to early marriage among females in India. According to the NACO document, in India, almost 50% of females are married before they reach 18 years of age.[56]

Among those who are sexually active, only 203 (37.7%) were practicing a long-standing, mutually monogamous relationship. The incidence of premarital contact was reported by 10% of males and 1% of females in our study. This is in comparison to the NFHS-3 study where 15% of young men and 4% of young women had experienced sexual contact before marriage.[11]

With regard to complete knowledge about condom usage, only 101 (8%) of the study group reported about its three-fold protection. The participants in the Group 1 and 2 as well as the female participants in all the subgroups reported lower scores in this domain. This is in concordance with a Delhi-based study by McManus and Dhar et al., in which 41% urban adolescent females did not know that condom can also prevent STIs other than HIV.[12] Another important aspect that we found in our study was that the higher the education status, the more complete their concept about condom usage and better knowledge about STI transmission [Figure 5]. This is in consistent with the observations of Sudha et al.[13] and Narasimhalu and Muhilan[14] where people with higher level of education were more informed about HIV/STI transmission than people with poor educational background.

Figure 5

Comparison of level of education and condom concept among participants

In the 15–24 age group, only 4% of young men and women reported that they received family life or sex education which is far below that of the national parameter of 15%.[15] This may probably due to high sociocultural restraints and inhibitions prevailing in our community in discussing issues about sex. The proportion of MSM is very high (33%) in our study when compared to that reported by Ghule and Donta[16] The present study was a cross-sectional study performed in a state referral center specialized in the management of venereal diseases, where maximum pooling of MSM cases could occur. Furthermore, many NGOs who provide targeted intervention for MSMs also refer patients to our institute. These two reasons could explain the higher incidence of MSMs in our study in comparison to other published data. Our study seems to indicate that, despite the cultural taboo and illegality of homosexuality in India, there are significant sections of youth practicing it. Seventy-two percent of MSM were promiscuous, and nearly half of them were practicing exclusive homosexuality which is similar to the study conducted by Garg et al. where promiscuity was seen in about 75% of MSM.[17] The sensitive nature of their act and high promiscuity put them at high risk of acquiring sexually transmitted diseases. We acknowledge that these findings are from the participants seeking heath care in a referral institution, and hence the results cannot be extrapolated to the general population.

Adolescent health programs are implemented by various ministries under the government of India.[181920212223] Still, we lack exclusive data for Indian youth- and adolescence-related health issues. Sivagurunathan et al.[24] have recommended that it is important to integrate all adolescent programs under one roof with a routine screening of this vulnerable age group. By this way, the felt needs of adolescents and youth pertaining to sexual practices can be understood in a better way, and demand-based services could be provided.

The limitations of our study include the retrospective nature of data collection and being a hospital-based study; it may not represent the general adolescent and young adult population in the society. The multiple parameters related to sexual activity were all self-reported which might have introduced the possibility of response bias from the participants. The strengths of the study include the larger number of study participants and evaluation of multiple risk factors that may lead to STI and HIV.

CONCLUSION

Our study depicts that a significant proportion of adolescents and young adults, who are the precious resource of our country, involve in risky sexual behavior, lack a complete knowledge about safe sex practices, and hence are at risk of acquiring HIV/STIs. The status of sex education and awareness also seems to be poor in the community. A multidisciplinary approach of sex education involving parents, teachers, government, and NGO, and strengthening of adolescent friendly reproductive services is mandatory. Since the majority of Indian youth at least complete their high school education, as also documented in our study (60%), a tailor-made sex education should be implemented in high school level itself, failing which it may have far-reaching implications on the future of our country and the world at large.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.