Methods: Focus group discussions were conducted with a range of young men in Vientiane, Laos; interviews were conducted with male sex workers. A questionnaire survey was conducted with a purposive sample of 800 young men.
Results: Most young men initiate sex at an early age and have multiple sex partners. Married men are more likely to pay for sex and most sex for money is negotiated in non-brothel settings. Despite high reported condom use for last intercourse with a casual partner, decisions on condom use are subjective. Many men have extramarital sex when their partner is pregnant and post partum. 18.5% of men report having had sex with another man; most of these men also report having sex with women. Moreover, more men report having had anal sex with a woman than with a man.
Conclusions: Although not a probability sample survey, this study of a broad range of young men in Vientiane reveals sexual behaviours that could lead to accelerated HIV transmission. Education should emphasise the need to use condoms in all sexual encounters outside the primary relationship. This needs special emphasis when the partner is pregnant or post partum. Advice on safe sex with other men needs to be integrated into all sexual health education for young men.
- FGD, focus group discussion
- STI, sexually transmitted infections
- HIV prevention
- young men
- sex in pregnancy
- men who have sex with men
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Laos is a small country with a low prevalence of HIV infection (<0.1%) surrounded by larger neighbours with high prevalence.1 While the risk of an epidemic on the scale of Thailand, Burma, or Cambodia is considered low, there has been inadequate information regarding sexual behaviour to reach that conclusion.2 Effective prevention needs to be based on a sound understanding of sexual practices and attitudes. Therefore, we undertook a study of the sexual behaviour of young men in Vientiane between August and November 2004.
We used a combination of qualitative and quantitative methods. The study was approved by the ethics committee of the Lao Ministry of Public Health. A focus group discussion (FGD) is a planned and guided discussion among the participants of a selected group, for the purpose of examining a particular issue, and an established method of qualitative inquiry. FGDs were facilitated with a range of young men by three teams of two young Lao men trained in research methods. FGDs took place in entertainment venues, restaurants, sporting venues, construction sites, and factories. Each had 5–6 participants aged 18–35 years and took 1–2 hours. Confidential semi-structured interviews were conducted with male sex workers. Except for discussions with sex workers, FGDs were recorded by audiotape if participants consented. The tapes and/or verbatim notes were forwarded to Melbourne for analysis by AX.
A survey was conducted among a purposive sample of 800 men aged 18–30 years. Vientiane was divided into three areas and each team visited randomly selected places within their assigned area. Study sites were monitored for diversity of location on a weekly basis. The questionnaire comprising 29 questions was precoded, written in Lao, and pilot tested. The purpose of the survey was explained and verbal consent obtained. The anonymous questionnaires were completed in private. Data were entered in EpiData 3.0 and Epi-Info 6 used for analysis.
Twenty nine FGDs were conducted: three each with labourers, openly gay men, transvestites, and entertainment venue or hotel workers; two with factory workers; two with sex workers; one with soldiers; and 12 with general young men. Interviews were conducted with 12 sex workers. (We use the term “gay” because this is the word most often used in the Lao language by study participants to refer to men who identify as preferring to have sex with men.)
The questionnaire was completed by 800 young men recruited at homes or dormitories (16.3%); sporting venues (15%); entertainment venues (14.3%); public parks (15%); restaurants (8.9%); workplaces (8.7%); markets (8.3%); colleges (6.8%); and other places such as streets, temples, and churches (10%). Twenty five questionnaires were excluded because they were either blank or contained little information beyond age.
The median age of respondents was 23 years. Over 90% had completed high school, which differs markedly from the national figure of 12% for urban males.3 Twenty per cent were married. The median age of first sexual experience with another person leading to orgasm was 18 years (fig 1); 67% of respondents reported that they masturbate regularly; frequency was related to age and marital status.
Sexual experiences with women
Among unmarried men, 82% reported having ever had sex and almost 40% said they currently had a steady sexual partner. Vaginal sex is common, although men reported having experienced mutual masturbation (83%), fellatio (33%), cunnilingus (20%), sex between a woman’s thighs (15%), mutual oral sex (14%), and anal sex (11%).
During the first 6 months of 2004 the median number of female sexual partners was two, with a broad range (fig 2); 60% of married men reported having two or more female sexual partners during this period. Young men expressed concern for their partner’s sexual pleasure through foreplay, extended intercourse, and artificial methods including threading a ring or goat’s hair through the foreskin, inserting foreign bodies under the penile skin, or injecting olive oil into the shaft of the penis. Many men were familiar with stories of abscesses and severe infections resulting from these practices; such complications have been reported in the medical literature.4
Paying women for sex
In all, 41% of men reported having ever paid for sex with a woman. In the first half of 2004, 32% paid for sex at least once—26% of single men and 50% of married men. They were more likely to buy sex from women at nightclubs, discos, and beer shops than brothels.
A condom was reportedly used during last sex with a non-regular female partner by 73% of respondents. Married men were slightly more likely than single men to report always using a condom (45% versus 41%) (fig 3). Although there was a high level of awareness of condoms and HIV and STI prevention, there were a number of beliefs that led to selective use. Firstly, there is the idea that a person’s HIV status can be assessed by her/his appearance. Many men said that “if women look good, dress well, and come from a good background” there is no need to use a condom. Secondly, most men stated that condoms reduce sexual feelings for both men and women. Thirdly, the use of condoms in an established relationship is considered a sign of mistrust. Some men did say that using a condom increases their confidence that they will not acquire an STI. Men were more likely to wear a condom with “service women” “but not use [them] with beautiful service women or with steady sex partners who know them well.” Male sex workers and transvestites shared these common attitudes believing that a person’s appearance and character are associated with their likelihood of carrying HIV. (The term “service woman” is a direct translation from the Lao phrase phuxao bolikan and refers to a woman working in any service industry, such as nightclubs, bars, and coffee shops. Most of the study participants used this term to refer to women selling sex.)
Sexually transmitted infections
FGD participants believed that STIs are frequent among young men, penile discharge and genital warts being the most common. The purchase of over the counter medications and seeking the advice of friends rather than a qualified doctor appear to be the norm. Men commonly wash their penis after unprotected intercourse with a variety of solutions in the belief that this provides protection.
Sex and pregnancy
Most men believed that sex in pregnancy poses a danger to the unborn child. Only 14% thought it appropriate to have sex during the second trimester, 5% in the third trimester, and 22% within 2 months after delivery; 64% of currently married men whose partner had ever been pregnant reported having sex with another person during the most recent pregnancy. Sex took place with “service women,” casual partners, steady girlfriends, and other men.
Sex with men
In all, 18.5% of men reported having sex at least once with another man, of whom 55% reported having had anal sex (fig 4). In the first half of 2004, 8% of men had sex with at least one man and one woman. Reported condom use during last anal sex (74%) was similar to that reported for vaginal sex with non-regular female partners (73%). Lubricant use with anal sex between men (44%) was higher than for men having vaginal sex with women (14%).
Men in FGDs admitted that some “complete” men sometimes have sex with other men when they are drunk and unable to have sex with a woman; some occasionally do it for money. Most sex workers identify as “complete” men. Many come from provincial areas, have little family support, and may be from ethnic minorities. They engage in the work for financial reasons. (The term “complete man” is derived from the Lao phrase phuxay tem tua, which translates literally as “full bodied man” and is commonly used among young Lao men of all types to describe heterosexual or “straight” men.)
Sex workers are usually the insertive partner and report having female as well as male clients. Understanding of the mode of HIV and STI transmission and prevention seemed to be poorer among sex workers than other men.
Limitations of the study
The survey used purposive rather than random sampling. However, men were surveyed in a range of different settings. We analysed the responses to questions on sex with service women, number of female partners, and ever having sex with a man according to where men were recruited. We found no significant difference between men recruited in entertainment venues, restaurants, and parks and men recruited in other settings. Our sample had higher average education status than the national figure for urban men. This is likely to reflect higher levels of education in Vientiane compared to other urban centres. The findings from the FGDs with less educated men suggest they share the risky behaviours and beliefs of the more educated survey sample.
Implications of the study
Young men in Vientiane have multiple sexual partners, frequent interaction with sex workers, and an incomplete understanding of HIV prevention. Consequently, men engage in sexual behaviours that could facilitate the spread of STIs, including HIV. The risk of a heterosexual HIV epidemic may be even greater if young Lao women, like their counterparts in Thailand, are shedding the protective effects of social norms and beginning to experience premarital sexual relationships.5
Because most Vientiane men commence sexual activity around the age of 16–18 years, sexual health education needs to begin in elementary and middle school before adolescents become sexually active. Although most young Vientiane men understand that condoms are protective, they accepted that negotiating unpaid sex with casual partners is relatively safe and a condom is not necessary. This is similar to attitudes among men in Thailand, where the waning patronage of brothels has seen a rise in casual sex with low condom use.6 None the less, Vientiane men reported using condoms with both sexes more frequently than Thai men in the 1990s.7,8 There was little acknowledgement among men that drinking and taking other drugs adds to their risk—another indication that individuals perceive little personal risk.
Prevention programmes should offer young people information about the range of options to protect themselves from HIV, such as avoiding penetrative sex. Our results show that non-penetrative forms of sex are familiar and practised by some, suggesting that this approach might be effective. More men reported having anal sex with women than with men, which puts some Lao women at high risk of HIV and STIs. This highlights the need for education programmes for men and women to focus on the risk of particular sexual practices.
Our findings indicate that married men need to be the main target for the promotion of condom use with service women. Most commercial sex in Vientiane is indirectly provided by “service women” working in restaurants, factories, and beer and coffee shops. Therefore, focusing the promotion of condoms predominantly to sex workers and their clients, as in Thailand’s “100% condom campaign,” might be difficult to implement and less effective in Laos where brothels are rare.
If a man becomes infected through extramarital sex during pregnancy he is likely to be very infectious when he resumes having sex with his wife.9 A woman is more susceptible to HIV infection during pregnancy and in the postpartum period.10 If she becomes infected she will experience the peak in viral load during labour or in the early weeks of breastfeeding—the times of greatest risk of transmission of HIV to the baby.11 Men need to know that they put their wife and child at risk of infection with HIV when they have unprotected sex outside marriage during pregnancy and in the postpartum period.9
Opportunities to provide this information include introducing a routine antenatal couple visit, training male counsellors in health facilities to talk to fathers and provide condoms when they collect their newborn baby, and talking to men as well as women at postnatal home visits.9 It is important to teach healthcare workers that sex at any stage of normal pregnancy does not harm the fetus, encourage them to explain this to pregnant women and their husbands, and develop appropriate counselling materials.
Almost one in five men reported having sex at least once with another man and more than one in 10 said they had a recent sexual encounter with another man. No comparable studies have been done on this topic in Laos. However, the largest such study in Thailand in 1996 consisted of confidential questionnaires completed by 4892 21 year old military conscripts. Overall, 17% reported ever having sex with a man; in Khon Kaen and Udonthani the figures were 17% and 18%, respectively.12 Thus, the behaviour in Vientiane in this regard is similar to men in northeast Thailand in the mid-1990s. Our data suggest that many men who have sex with men also have sex with women and do not necessarily identify themselves as “gay.” The role of this behaviour in the spread of HIV has been described in several Asian countries.13–16
Thailand’s experience is relevant—although condom promotion among the clients of female sex workers was successful, the issue of men who have sex with men was neglected.5 Recent studies have found high levels of HIV and low rates of condom use among these men.17 Failing to address the potentially high risk of HIV transmission among Lao men who have sex with men and those men who sell sex would be a missed opportunity to prevent one mechanism for transmitting HIV into the general sexually active population.
The evidence that Lao sex workers think of themselves as “complete men” and behave in a bisexual manner suggests that programmes focused on homosexually active men may not succeed in addressing the sexual health needs of this group. Studies of male sex workers in Thailand reveal similar behavioural patterns.18 Promotion of “100% condom use” is one important element of a comprehensive education programme needed for male sex workers in Vientiane.
The study shows that in a low prevalence country such as Laos there should not be complacency and there are risk factors for accelerated sexual transmission that must not be ignored by decision makers. The epidemic may merely be growing at a slower pace than in neighbouring countries where a brothel based sex industry plus or minus injecting drug use led to explosive epidemics. The same behaviours should be studied in other low prevalence Asian countries, such as Sri Lanka, the Philippines, and Bangladesh
Although there is a high level of knowledge and understanding of HIV and STI transmission among young men there is a gap between knowledge and practice, with condom use based on subjective decision making. The fact that men use condoms irregularly is underscored by the finding in FGDs that STIs are common among young men in Vientiane
Common misunderstandings about the safety of sex during pregnancy and the subsequent common practice of extramarital sex by men during their partner’s pregnancy have important implications for the prevention of mother to child HIV transmission (PMTCT). They highlight the importance of primary prevention within a comprehensive approach (Prong 1 of the international strategy for PMTCT)
The findings on sex between males are important for prevention programs to understand and take into consideration. We found that most men who have sex with men also have sex with women and do not identify as homosexual. Therefore, they cannot be easily identified and need to have access to integrated sexual health education. Moreover, anal sex between men and women is more common than between men (according to our study). Therefore, young women also need access to frank sexual health education that includes discussion of the high risk associated with this behaviour if a condom and lubricant are not used
Integrated sexual health education programmes for men need to be expedited. Our data suggest that most sexual interactions among young unmarried Lao people are not of a commercial nature. It is important to study the sexual behaviour, beliefs, and concerns of young women as well as men, and implement effective programmes to provide both young men and young women with the knowledge and understanding they need to protect themselves.
We thank the young men who conducted this research: Sounivanh Phimlavone, Siphan Inthasak, Somlath Vongsipaseuth, Tulakon Singhavong, Bunpaseuth Oupalivong, and Phonxay Mingvanmeung. Field supervision was initially provided by Khampone Vichithavong of the Burnet Institute, Vientiane. Damian Hoy (Burnet Institute, Vientiane) trained two of the researchers in quantitative data entry.
Dr Sithat Insisisengmay helped guide the study proposal through the ethics committee of the Lao Ministry of Public Health.
CONTRIBUTORS MT, principal investigator, design of study, training of researchers, oversight, and primary author; BC, design of data entry program and analysis of all survey data; AX, analysis of all qualitative data (transcripts and tapes in Lao language); WH, principal adviser on the qualitative aspects of the study and major input into the revision of the first draft of the paper; SP, responsible for day to day supervision of field studies, researchers, and data entry; NC, responsibility for original idea of study, negotiation with and reporting to the funding agency, obtaining approval from the Lao Government, and submission of the study protocol to the ethics committee.
Funding for the study was provided by the Royal Netherlands Embassy in Bangkok, Thailand.
Conflicts of interest: The authors declare that they have no conflicts of interest associated with this study.
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