Early sexual debut among young men in rural South Africa: heightened vulnerability to sexual risk?
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《性传输感染》
1 Division of Infectious Diseases, Department of Medicine and Population Studies and Training Center, Brown University, Providence, RI, USA, and HIV Prevention Research Unit, South African Medical Research Council, Durban, South Africa
2 Centre for Population Studies, London School of Hygiene and Tropical Medicine, University of London, 50 Bedford Square, London WC1, UK
3 16 Rue de la Canonniere, 1202 Geneva, Switzerland
4 Centre for AIDS Programme of Research in South Africa (CAPRISA), Nelson Mandela School of Medicine, University of KwaZulu/Natal, Durban, South Africa
ABSTRACT
Objective: This report examines early sexual debut (
Methods: Analysis of sexual behaviour data for men 15–24 years (n = 314) from representative cross sectional household survey.
Results: 13.1% of 15–24 year old men experienced sexual debut before age 15. Men with sexual debut at less than age 15 were more likely to report risk behaviours at first sexual experience: no condom use (19%), a casual partner (26.8%), and not feeling they had been "ready and wanted to have sex" (19.5%). In multivariate analysis, early sexual debut was strongly associated with 3 partners in the past 3 years (OR = 10.26, p<0.01).
Conclusions: Men who initiate sex before age 15 form a distinct risk group in this setting. Specific interventions are needed for young men in the preteen years, before sexual debut.
Keywords: sexual debut; South Africa
Young people bear the burden of South Africa’s severe HIV epidemic, with 10.2% of 15–24 year olds infected with HIV nationally.1 In response, recent research in South Africa has addressed sexual risk behaviours among young people, particularly women.2–5 A significant gap in the literature exists, however, with regard to young men: their needs and concerns have received relatively scant attention.6
Age at first sex is an important indicator of sexual risk, as it marks the onset of exposure to infection, is a risk factor for HIV infection,7 and is a key indicator for monitoring response to the HIV epidemic among youths. However, there is little quantitative information about men’s experiences of sexual debut in sub-Saharan Africa, except a few national surveys that included men.8
This report is based on analysis of sexual behaviour data from a cross sectional household survey in rural KwaZulu/Natal, South Africa. We examine young men’s experiences of sexual debut, and the association of early sexual debut with involvement in multiple partnerships.
METHODS
A household census of adults aged 15–49 (n = 2309) was conducted in a rural subdistrict of KwaZulu/Natal province, a severely HIV affected area with prevalence of 14.1% in 15–24 year olds in 2003.1 Annual per capita income is under $US 1200. The survey included 314 young men aged 15–24, of whom 62.7% were sexually active.
Bivariate associations between age at sexual debut and first sexual experiences were examined. Age at sexual debut was then included in the multivariate analysis to examine associations with the main outcome: 3 partners in the past 3 years. A logistic regression model examined relations between independent and dependent factors after adjustment for all other covariates. Multivariate analysis of the main outcome was restricted to those with sexual debut at least 3 years before the survey (n = 122), as the recently sexually experienced would have lacked sufficient time for partner accumulation. Explanatory variables were limited to more static measures, since sexual debut was a past event. However, some current status variables (education, media exposure, familial circumstances) were included, as relatively recent measures in the 15–24 age group. Main measures were defined as: (1) sexual debut: "at what age did you start your first sexual relationship?" and (2) 3 partners in past 3 years: "how many sexual partners have you had within past three years?" selected as an appropriate period in which to measure multiple partnerships in this age group.
Explanatory factors came from a household schedule administered with the survey. Household wealth was measured from an asset index. Parental residence was defined as living with both, one or no parents, while community participation included membership in one or more of sports, church, singing, dance, or study groups.
Ethical approval to conduct this research was obtained from the ethics review committees of the Faculty of Medicine, University of Natal, Durban, South Africa and the University of London (London School of Hygiene and Tropical Medicine), London, UK.
RESULTS
In all, 13.1% of men 15–24 years of age reported their first sexual relationship before age 15 (range 9–14 years).
Significant associations were found between age at sexual debut and key measures of first sexual experience (table 1). The proportion of men reporting they had been ready and wanted to have sex at that time increased with age at first sex. The proportion that did not know their partner well decreased as age at first sex rose, as did the proportion that had been in love at the time of sexual debut. No respondents indicated they had experienced coercion or had a stranger as their first partner.
Significant differences were observed in condom use at first sex between men who initiated sex at age 15 compared to those who initiated earlier (19% v 9%, p<0.05), 35.2% reported 3 partners in the past 3 years, while 42.3% and 23.5% reported one and two partners respectively. Only 11.2% reported 5 partners in the past 3 years. In multivariate analysis (table 2), earlier sexual debut was the only significant predictor of 3 partners in the past 3 years (OR = 10.26, p<0.01).
DISCUSSION
Young men in rural South Africa with early sexual debut exhibit a constellation of risk factors for HIV infection, and also later sexual risk.
Young men reporting sexual debut before age 15 were more likely not to use condoms at first sex, to have had multiple and casual partners, and to say they "had not been ready and wanted to have sex." Young men with early sexual debut were 10 times more likely to have had multiple partners, even after controlling for duration of sexual activity, reinforcing evidence that early sexual experiences may determine sexual risk behaviours throughout the life course.9 Importantly, risk behaviours, once established, may be difficult to change.
Yet in-depth interpretation of these findings is difficult. Being "in love" and having been "ready and wanted to have sex at that time" are not mutually exclusive, nor is it clear how these are associated with other risk behaviours. Qualitative findings6,10 indicate reasons that young men initiate sexual activity: peer pressure, asserting masculinity, relations with older women, and sexual abuse, which is likely under-reported. Although only 3.5% of young men reported sexual debut age 12, other South African studies indicate high levels of childhood sexual abuse.11
Limitations to this analysis include possible bias in reporting of sexual behaviours, exaggeration of sexual activity and numbers of partners,12 and the 3 year length of the recall period for number of partners. Further, the definition of "sexual debut" as "age at sexual first sexual relationship" might have neglected some sexual activity outside established relationships.
This study is exploratory, raising questions about the dynamics of young men’s relationships, vulnerability, and sexual risk. What are the pathways to risk among young men with early sexual debut? Are they indeed vulnerable, having had unwanted sexual activity at an early age, and thus forfeiting opportunities to develop a healthy sexuality including protection from risk? Or are they a subgroup of sexually confident young men whose high risk status is reflected in the later accumulation of multiple partners?
Whatever the reasons, these findings highlight a troubling lack of preparation for sexual activity among young men in this setting. Further research should be directed toward better understanding young men’s early relationships and sexual experiences, and to the design of interventions for pre-adolescent young men, before sexual debut. Interventions for young men should emphasise condom promotion, as well as delay in sexual activity.
ACKNOWLEDGEMENTS
The authors gratefully acknowledge financial support from the Fogarty International Center, National Institutes of Health, USA, through a grant to the South African Medical Research Council, and the Wellcome Trust, Population and Health Programme, London, UK.
CONTRIBUTORS
AH, primary role in writing all sections of paper, analysis of survey data on youth, and design of sexual behaviour questionnaire; JC, technical and scientific contributions to questionnaire design, data analysis, manuscript preparation; EG, primary role in survey design, analysis of data for full survey, statistical input to manuscript; JF, survey design, implementation, manuscript review
FOOTNOTES
Competing interests: There are no competing interests to declare.
REFERENCES
Pettifor A, et al. HIV and sexual behaviour among young South Africans: national survey of 15–24 year olds. Johannesburg: Reproductive Health Research Unit, University of the Witwatersrand, 2004.
Eaton L, Flisher AJ, Aaro LE. Unsafe sexual behaviour in South African youth. Soc Sci Med 2003;56:149–65.
Harrison A, Xaba N, Kunene P. Understanding safe sex: gender narratives of HIV and pregnancy prevention by rural South African school-going youth. Repro Health Matters 2001;9:63–71.
Wood K, Maforah F, Jewkes R. "He forced me to love him": putting violence on adolescent sexual health agendas. Soc Sci Med 1998;47:233–42.
MacPhail C, Campbell C. "I think condoms are good but, aai, I hate those things": condom use among adolescents and young people in a Southern African township. Soc Sci Med 2001;52:1613–27.
Varga CA. The Forgotten Fifty Per Cent: A review of sexual and reproductive health research and programs focused on boys and young men in sub-Saharan Africa. Afr J Repro Health 2001;5:175–95.
Gregson S, et al. Sexual mixing patterns and sex-differentials in teenage exposure to HIV infection in rural Zimbabwe. Lancet 2002;359:1896–903.
Gupta N, Mahy M. Sexual initiation among adolescent girls and boys: trends and differentials in sub-Saharan Africa. Arch Sex Behav 2003;3:41–53.
White R, Cleland J, Carael M. Links between premarital sexual behaviour and extramarital intercourse: a multi-site analysis. AIDS 2000;14:2323–31.
Harrison A . The social dynamics of adolescent risk for HIV: using research findings to design a school-based intervention. Agenda 2002;53:43–52.
Jewkes R, Levin J, Mbananga N, et al. Rape of girls in South Africa. Lancet 2002;359:19–20.
Nnko S, Boerma JT, Urassa M, et al. Secretive females or swaggering males? An assessment of the quality of sexual partnership reporting in rural Tanzania. Soc Sci Med 2004;59:299–310.(A Harrison, J Cleland, E )
2 Centre for Population Studies, London School of Hygiene and Tropical Medicine, University of London, 50 Bedford Square, London WC1, UK
3 16 Rue de la Canonniere, 1202 Geneva, Switzerland
4 Centre for AIDS Programme of Research in South Africa (CAPRISA), Nelson Mandela School of Medicine, University of KwaZulu/Natal, Durban, South Africa
ABSTRACT
Objective: This report examines early sexual debut (
Methods: Analysis of sexual behaviour data for men 15–24 years (n = 314) from representative cross sectional household survey.
Results: 13.1% of 15–24 year old men experienced sexual debut before age 15. Men with sexual debut at less than age 15 were more likely to report risk behaviours at first sexual experience: no condom use (19%), a casual partner (26.8%), and not feeling they had been "ready and wanted to have sex" (19.5%). In multivariate analysis, early sexual debut was strongly associated with 3 partners in the past 3 years (OR = 10.26, p<0.01).
Conclusions: Men who initiate sex before age 15 form a distinct risk group in this setting. Specific interventions are needed for young men in the preteen years, before sexual debut.
Keywords: sexual debut; South Africa
Young people bear the burden of South Africa’s severe HIV epidemic, with 10.2% of 15–24 year olds infected with HIV nationally.1 In response, recent research in South Africa has addressed sexual risk behaviours among young people, particularly women.2–5 A significant gap in the literature exists, however, with regard to young men: their needs and concerns have received relatively scant attention.6
Age at first sex is an important indicator of sexual risk, as it marks the onset of exposure to infection, is a risk factor for HIV infection,7 and is a key indicator for monitoring response to the HIV epidemic among youths. However, there is little quantitative information about men’s experiences of sexual debut in sub-Saharan Africa, except a few national surveys that included men.8
This report is based on analysis of sexual behaviour data from a cross sectional household survey in rural KwaZulu/Natal, South Africa. We examine young men’s experiences of sexual debut, and the association of early sexual debut with involvement in multiple partnerships.
METHODS
A household census of adults aged 15–49 (n = 2309) was conducted in a rural subdistrict of KwaZulu/Natal province, a severely HIV affected area with prevalence of 14.1% in 15–24 year olds in 2003.1 Annual per capita income is under $US 1200. The survey included 314 young men aged 15–24, of whom 62.7% were sexually active.
Bivariate associations between age at sexual debut and first sexual experiences were examined. Age at sexual debut was then included in the multivariate analysis to examine associations with the main outcome: 3 partners in the past 3 years. A logistic regression model examined relations between independent and dependent factors after adjustment for all other covariates. Multivariate analysis of the main outcome was restricted to those with sexual debut at least 3 years before the survey (n = 122), as the recently sexually experienced would have lacked sufficient time for partner accumulation. Explanatory variables were limited to more static measures, since sexual debut was a past event. However, some current status variables (education, media exposure, familial circumstances) were included, as relatively recent measures in the 15–24 age group. Main measures were defined as: (1) sexual debut: "at what age did you start your first sexual relationship?" and (2) 3 partners in past 3 years: "how many sexual partners have you had within past three years?" selected as an appropriate period in which to measure multiple partnerships in this age group.
Explanatory factors came from a household schedule administered with the survey. Household wealth was measured from an asset index. Parental residence was defined as living with both, one or no parents, while community participation included membership in one or more of sports, church, singing, dance, or study groups.
Ethical approval to conduct this research was obtained from the ethics review committees of the Faculty of Medicine, University of Natal, Durban, South Africa and the University of London (London School of Hygiene and Tropical Medicine), London, UK.
RESULTS
In all, 13.1% of men 15–24 years of age reported their first sexual relationship before age 15 (range 9–14 years).
Significant associations were found between age at sexual debut and key measures of first sexual experience (table 1). The proportion of men reporting they had been ready and wanted to have sex at that time increased with age at first sex. The proportion that did not know their partner well decreased as age at first sex rose, as did the proportion that had been in love at the time of sexual debut. No respondents indicated they had experienced coercion or had a stranger as their first partner.
Significant differences were observed in condom use at first sex between men who initiated sex at age 15 compared to those who initiated earlier (19% v 9%, p<0.05), 35.2% reported 3 partners in the past 3 years, while 42.3% and 23.5% reported one and two partners respectively. Only 11.2% reported 5 partners in the past 3 years. In multivariate analysis (table 2), earlier sexual debut was the only significant predictor of 3 partners in the past 3 years (OR = 10.26, p<0.01).
DISCUSSION
Young men in rural South Africa with early sexual debut exhibit a constellation of risk factors for HIV infection, and also later sexual risk.
Young men reporting sexual debut before age 15 were more likely not to use condoms at first sex, to have had multiple and casual partners, and to say they "had not been ready and wanted to have sex." Young men with early sexual debut were 10 times more likely to have had multiple partners, even after controlling for duration of sexual activity, reinforcing evidence that early sexual experiences may determine sexual risk behaviours throughout the life course.9 Importantly, risk behaviours, once established, may be difficult to change.
Yet in-depth interpretation of these findings is difficult. Being "in love" and having been "ready and wanted to have sex at that time" are not mutually exclusive, nor is it clear how these are associated with other risk behaviours. Qualitative findings6,10 indicate reasons that young men initiate sexual activity: peer pressure, asserting masculinity, relations with older women, and sexual abuse, which is likely under-reported. Although only 3.5% of young men reported sexual debut age 12, other South African studies indicate high levels of childhood sexual abuse.11
Limitations to this analysis include possible bias in reporting of sexual behaviours, exaggeration of sexual activity and numbers of partners,12 and the 3 year length of the recall period for number of partners. Further, the definition of "sexual debut" as "age at sexual first sexual relationship" might have neglected some sexual activity outside established relationships.
This study is exploratory, raising questions about the dynamics of young men’s relationships, vulnerability, and sexual risk. What are the pathways to risk among young men with early sexual debut? Are they indeed vulnerable, having had unwanted sexual activity at an early age, and thus forfeiting opportunities to develop a healthy sexuality including protection from risk? Or are they a subgroup of sexually confident young men whose high risk status is reflected in the later accumulation of multiple partners?
Whatever the reasons, these findings highlight a troubling lack of preparation for sexual activity among young men in this setting. Further research should be directed toward better understanding young men’s early relationships and sexual experiences, and to the design of interventions for pre-adolescent young men, before sexual debut. Interventions for young men should emphasise condom promotion, as well as delay in sexual activity.
ACKNOWLEDGEMENTS
The authors gratefully acknowledge financial support from the Fogarty International Center, National Institutes of Health, USA, through a grant to the South African Medical Research Council, and the Wellcome Trust, Population and Health Programme, London, UK.
CONTRIBUTORS
AH, primary role in writing all sections of paper, analysis of survey data on youth, and design of sexual behaviour questionnaire; JC, technical and scientific contributions to questionnaire design, data analysis, manuscript preparation; EG, primary role in survey design, analysis of data for full survey, statistical input to manuscript; JF, survey design, implementation, manuscript review
FOOTNOTES
Competing interests: There are no competing interests to declare.
REFERENCES
Pettifor A, et al. HIV and sexual behaviour among young South Africans: national survey of 15–24 year olds. Johannesburg: Reproductive Health Research Unit, University of the Witwatersrand, 2004.
Eaton L, Flisher AJ, Aaro LE. Unsafe sexual behaviour in South African youth. Soc Sci Med 2003;56:149–65.
Harrison A, Xaba N, Kunene P. Understanding safe sex: gender narratives of HIV and pregnancy prevention by rural South African school-going youth. Repro Health Matters 2001;9:63–71.
Wood K, Maforah F, Jewkes R. "He forced me to love him": putting violence on adolescent sexual health agendas. Soc Sci Med 1998;47:233–42.
MacPhail C, Campbell C. "I think condoms are good but, aai, I hate those things": condom use among adolescents and young people in a Southern African township. Soc Sci Med 2001;52:1613–27.
Varga CA. The Forgotten Fifty Per Cent: A review of sexual and reproductive health research and programs focused on boys and young men in sub-Saharan Africa. Afr J Repro Health 2001;5:175–95.
Gregson S, et al. Sexual mixing patterns and sex-differentials in teenage exposure to HIV infection in rural Zimbabwe. Lancet 2002;359:1896–903.
Gupta N, Mahy M. Sexual initiation among adolescent girls and boys: trends and differentials in sub-Saharan Africa. Arch Sex Behav 2003;3:41–53.
White R, Cleland J, Carael M. Links between premarital sexual behaviour and extramarital intercourse: a multi-site analysis. AIDS 2000;14:2323–31.
Harrison A . The social dynamics of adolescent risk for HIV: using research findings to design a school-based intervention. Agenda 2002;53:43–52.
Jewkes R, Levin J, Mbananga N, et al. Rape of girls in South Africa. Lancet 2002;359:19–20.
Nnko S, Boerma JT, Urassa M, et al. Secretive females or swaggering males? An assessment of the quality of sexual partnership reporting in rural Tanzania. Soc Sci Med 2004;59:299–310.(A Harrison, J Cleland, E )