Health Science Journal

Keywords

Perceptions, Media, South Asia

Background

Research activities aimed at investigating sexual behaviour and assessing interventions to improve sexual health have increased globally in recent decades [1]. Indeed, with the advent of the HIV (Human Immunodeficiency Virus) epidemic, sex and sexuality issues have become a major public health concern which, in turn, generated the need for studies which identify people’s attitudes, beliefs and behaviour towards sexual and reproductive health [2]. However, there is very limited literature in the field of young people’s sexual health in Nepal, which is not surprising for a society where talking about sexual matters is still taboo [3,4]. Although there are a few studies [5-7] which provide in-depth views on sexual behaviour among Nepalese young people, most studies have focused particularly on knowledge, attitude and belief towards sex and sexuality [4,8-10]. Studies and interventions on young Nepalese people’s sexual behaviour have also focused overwhelmingly on those attending school and/or college [8,11,12].

It is generally accepted that sexual activity can have both positive and negative outcomes for people of any age [13]. There is evidence that Sexually Transmitted Infections (STIs) and unwanted pregnancies are high among people who initiate sexual activity earlier [14,15]. Perhaps it can be argued that they often engage in risky sexual behaviour. Although there was once a general (mis)-perception that unmarried adolescents rarely engaged in sexual relationships1 [6], it is now widely acknowledged that adolescence is a key period of sexual exploration and development [6,17]. The literature also suggests that an increasing proportion of unmarried young people are sexually active [7,18]. Therefore, many health care providers, researchers and policy makers have shown substantial interest in understanding why young people initiate sexual intercourse progressively at early age [19]. In Nepal, the Ministry of Health has also promoted abstinence and delay of sexual activity as one of the strategies for young people to reduce the risk of STIs and HIV [20].

Limited published literature suggests that the Nepalese culture still perceives sexuality as taboo and does not excuse sexual activities outside marriage4 and pregnancy outside marriage is catastrophic [21]. However, attitudes of the young generation towards sexual relationships has steadily changed with the modernisation of society and culture due to increased exposure to the global network of television, internet, movies and other means of information. Boys and girls in Nepal are also now more comfortable being around each other [22], at a much earlier age and more frequently than in previous decades. Bott and colleagues [23] pointed out that many South Asian boys and girls spend more years in education and marry later. It may also create more opportunities for them to spend more time in intimate (sexual) relationships before marriage. Evidence suggests that a significant proportion of young people in Nepal engage in premarital sexual activities. For example, a previous study carried out in Nepal [24] reported that only 15% of young boys engaged in premarital sexual intercourse. Another study carried out among school-going adolescents reported that 10% of its sample had experienced premarital sex [25]. Similarly, a factory study conducted in Kathmandu showed that 35% of unmarried boys and 16% unmarried girls have experienced sex [26]. A recent study carried out among college students of Kathmandu has found that almost 40% of young men reported premarital sex [7]. These findings highlight that young people in Nepal start sexual activities at an early age and also suggest that this trend of prevalence of premarital sex among adolescent and young people have been increasing noticeably.

Previously, many factors such as peer pressure [19], increasing socio-economic problems [27] and delayed marriage [23] have been reported as direct or indirect factors for encouraging premarital sexual activity among young people in other geographical settings. Most previous studies in Nepal have focused on the prevalence of premarital sex and have ignored those factors encouraging premarital sexual behaviour among young people. This qualitative study attempts to explore the encouraging factors for premarital sex among Nepalese young people.

This paper uses the terms young women and girls as well as young men and boys interchangeably. We are aware there is a difference between the terms, but this is the way the young people in our studies used them.

Methods

Sensitive sexual issues are best studied using qualitative methods [28]. Such approaches have been widely used in studies of sexuality and sexual behaviour in Nepal and elsewhere. This qualitative study consisted of ten focus groups and 31 individual in-depth interviews conducted with young people in Nepal. Most of the focus groups and in-depth interview participants were aged between 18 and 22 years. Participants were selected purposively from major urban and rural districts of Kathmandu and Chitwan. Four colleges and one youth club from Kathmandu and three colleges and two youth clubs from Chitwan district were selected. Both college-based and school drop-out focus groups were largely drawn from pre-existing groups. In Nepal, it is not acceptable to conduct interviews about sexual issues with an opposite sex interviewer. Hence, same sex researchers conducted FGDs and in-depth interviews. A focus group schedule or questioning route approach [29] was developed in Nepali, and an interview topic guide for the semi-structured in-depth interviews. All FGDs and interviews were also conducted in Nepali language in a comfortable environment to assure confidentiality. These were tape-recorded and generally lasted between one and two hours. Tapes were transcribed verbatim and data was organised with the help of NVivo software. A thematic approach [30] was used to analyse the data, that is, categories (or themes or codes) were developed from the data set. Relevant quotes are also provided in the text to illustrate these categories. Ethical approval was granted by the Nepal Health Research Council, and an informed consent was obtained from participants prior to the study.

Results

Curiosity and pleasure

Our study found that curiosity and pleasure were the most frequently reported encouraging factors for premarital sexual practices. Most boys and girls shared that young people want to experience everything, including sexual practise. Participants also commonly agreed that sex-play gives more pleasure than any other activity so young people are often involved in sex activities, for example:

I think no other things give more pleasure than sex. We do that to get pleasure and fun (Focus Groups, Rural Males).

However, in a traditional society like Nepal, it was not just the boys who had such opinions, as this quote from a young woman illustrates:

We become very curious about sex at the age of 16-17. Some people may ignore it but some people want to feel it. It is also easy to do sex if you have boyfriend. Boys never say “No” if you request them for sex. I had my boyfriend so it became possible. We don’t think broadly at that stage…we just think about fun and short-term benefits (Urban Unmarried Female, 20).

Some participants believed that not being able to discuss sex with family and others in the community have made them more curious about sex and sexuality. They argued that society’s strict attitudes towards sex actually encouraged them to learn more about sexual matters, for example:

Our parents are very strict …When they do not allow us to do something then we start thinking like what happens if we do this and that? Sometime it makes us more curious and we attempt to do that. Sex is also similar thing (Focus Group, Male, School Drop-outs).

Role of media and porn CDs

Everybody agreed that young people had ‘easy’ access to sex and sexual health information, especially television and the internet; for example, participants made comments such as:

You get all information about sex on internet … and we cannot easily ignore this material (Urban Unmarried Female, 23).

Similarly, print and electronic media such as glossy magazines, TV channels, movies, porn CDs and DVDs were also frequently reported as encouraging factors for premarital sex. Most boys had learned many sexual issues from magazines and journals, movies, radio and TV. Most of the participants agreed that the media’s portrayal of sex and sexuality influenced young people, for example:

We watch TV and films, read papers and listen to the radio. It is all about sex. We become emotional and attempt to do such things. There are too many naked pictures found in papers and on the net. It really affects us (Urban Unmarried Female, 20).

Others argued that young people might want to do what they see in the media, e.g.:

Nowadays, both boys and girls use media, films and newspaper to pass their time. Boys and girls see blue films and want to do the same as what they see in film and newspapers. So they have premarital sex (Focus Group, Rural Females).

Urban participants concluded that the media provides ‘sex education’ and it encourages them to engage in sexual behaviours. The following example focuses on the internet:

We visit cyber café frequently…we don’t only check our emails but also visit other sites. We even sometime watch porn videos. What I guess is that most young boys learn about sex thing from that. It also really encourages us to do that in real life (Rural Unmarried Male, 18).

Natural phenomenon

Some participants suggested that sexual activity is a natural phenomenon and hence they argued that no one needs to learn about sex, it is spontaneous. The following quote makes an analogy with another natural habit, namely that of eating:

We eat rice when we feel hungry. Sex is also like that. There is no reason behind it. It is a natural process. You know, all animal do sex. They learn themselves (Focus Group, Urban Males).

Participants also reported that the practice of delayed marriage also encourages unmarried young people to engage in premarital sexual intercourse as they cannot wait until their marriage.

Main thing is the age…people marry at a higher age…so we cannot avoid sex as we all have such desires [laughs] (Focus Groups, Female, School Drop-outs).

Individual characteristics and appearance

It was reported that individual characters such as physical fitness and beauty, talent and appearance also influence premarital sexual behaviour. For example, most boys reported that they like to perform sexual intercourse with the girls who are beautiful and fashionable. Some girls also agreed that if boys are looking handsome then it is difficult to ignore or refuse them, for example:

He was a nice guy so I could not deny for sex (Urban Unmarried Female, 18).

Participants commonly agreed that individual characteristics such as beauty and talent encourage them to initiate sexual relationships, for examples:

Girls themselves also encourage us…for example, they wear short dresses…it stimulates us. When we see them, we only concentrate about how to persuade them for sex? (Focus Groups, Rural Males)

Get-up and make up also influence. If there is a very beautiful girl then we become very excited. If we see them in crowded places then we try to touch them [laughs] (Focus Groups, Urban Males).

Most participants also agreed that boys usually encourage or initiate sexual relations at first. Most of the boys and even some girls also shared that sexual opportunities should be taken when they occur. Similarly, boys and girls felt that if they trusted each other there is also a high chance of sexual relations.

We had sexual relations before our marriage…as we both believed in each other so I also agreed… I did not hesitate to do that because I was so sure that he will never break our relationship. He never pestered me (Urban Married Female, 24).

Money and gifts

Some young people engage in premarital sexual behaviour for money and gifts. Both rural and urban participants shared that it is possible to engage in sex before marriage for economic reasons. Many rural and some urban girls reported that they have less power and that they can be financially restricted. They also revealed that boys often offer financial help and try to exploit them, particularly expecting sex in return.

Some girls do it [sex] for money and some do it for fun... I remember that there was a married man who always asked me whether I need some supports from him. I knew his intention. If we anticipate some supports from men then they try to take something from us (Focus Groups, Urban Girls).

When you receive something like money, gifts from your friend then it is difficult to ignore their request (Focus Group, Rural Girls).

Boys also thought that money can help to initiate sexual intercourse, for example:

I tried to convince her for sex many times but she was never ready. When I offered some money indirectly then she agreed (Rural Unmarried Male, 18).

We know that the reasons for sex is for pleasure... but girls are lucky enough as they get both pleasure and money (Focus Group, Urban Males).

Contraceptives and sex education

Surprisingly, this study found that the availability of information and services about sexual matters and contraceptive methods might have encouraged young people to engage in premarital sex. Particularly availability and condoms and emergency contraceptives seem to encourage them to engage in sex..

My friends always asked me to put condom on. He says that nothing will happen if I use condoms. So I never feel fear... I just grab the opportunities (Rural Unmarried Male, 18, School Drop-outs).

We know about the emergency contraceptives. Even if you do unsafe sex, you can take that after the sexual intercourse. There is no point to worry about … no one knows whether you have done that [laughs]... I think these facilities also encourage us to do that (Focus Group, Urban Males)

They further argued that the reasons for not engaging in premarital sex are mainly due to the fear of HIV and pregnancies. However, participants suggested that better information about sexual and reproductive health issues and wider availability of condoms may have led them to engage in premarital sexual behaviour.

Peer supports and pressures

Both boys and girls frequently reported that peer pressure is very important in young people’s life. Boys argued that they mostly discuss sexual matters among friends. Girls also accepted that they are influenced by peers on sexual matters and initially on starting relationships. This study revealed that most boys share their sexual experiences to their friends and on most occasions they exaggerate their activities and also encourage their friends to do the same.

Our friends always share sex-related experiences. They say like “I had sex with that girl" we really had fun and so on. ..When we hear such message, we feel that we are far behind and also want to do the same. All these activities are happening with the supports of friends (Rural Unmarried Male, 18, School Drop-out).

If you and your partner ready for that [sex] then you don’t need anyone's help…but in reality, it does not happen... You always get information and supports from your friends. My friend encouraged me a lot for that…I had not thought that previously (Focus Group, Rural Males).

However some girls reported that only some girls share their sexual experience with other. Some boys revealed that their friends mediate or even arrange for sexual acts. Both boys and girls accepted that there is a huge demonstration effect, as the following quote illustrates:

Friends are one of the encouraging factors. If there are boys from foreign countries, they share their sexual experiences. We become very excited when we hear their experiences... After that we always want to complete that task [sex] (Rural Unmarried Male, 18).

Role of dating

Most FGDs and in-depth interviews suggested that dating encourages (early) sexual practices. Though most participants shared that young people date to share love, some urban and rural participants agreed that unmarried young people date for sexual purposes. Most argued that whether or not sexual intercourse takes place is determined by location, reason for dating and the character of the partners. All participants agreed that there is a high chance of sexual acts occurring if people organise a date at a secluded and quiet place, such as the jungle, hotels and private rooms. Here are some examples:

It all depends on where they go. If they go to a quiet place then there is a high chance of having sexual relations if there are only two people. Even if they are shy and feel afraid, they cross the limit. They may be so curious about that whenever they get the chance, they may act (Focus Group, Urban Females).

Strengthening love and threaten

Some participants reported that boys and girls engage in premarital sex to strengthen their partnership. Most girls have a belief that they become ready to do anything to make their love succeed.

When we are in love, we always think that we will be together forever... I am easily convinced when my boyfriend asks me for sex (Urban Unmarried Female, 21).

Some give more priority for sex…one of my friends claimed that sex has made their love even stronger (Rural Unmarried Girl, 21).

However, they also argued that some boys even pretend true love to fulfil their sexual desires. Discussions with some boys suggest very few couples continue to be lovers after the sexual encounter. In addition, participants also reported that boys or girls even threaten or force their partner into a sexual relationship. They reported that young people also often lie to trick a partner into sexual activities. One male participant told his story as follows:

I was close to a girl who was a daughter of a local shopkeeper. She used to study in another college. She used to stay in another area in a rented room. I used to go there frequently to see her... Once I stayed there in her room and slept with her. We had physical relationship there at that time. After some days she gave me a call and told that her menstruation stopped... I was very serious and worried. It was during our main festival [Dashain]. People were enjoying it but I felt nothing. I just used to think about that incident. We even planned for abortion but she insisted to go abroad [India] for it because what she said that if we do it here then all know about it. Then I borrowed 5/6000 rupees from my friend and went to see her. When I reached there she laughed a lot. I knew that she told me lie. She told me that she wanted to have sex with me again so she told me lie (Urban Unmarried Male, 24).

Discussion

Participants believed that exposure to mass media such as TV, CDs and the Internet, which contains sexual images and videos, encourages certain attitudes towards sex and may even encourage sexual behaviours itself. This suggests that most urban and some rural participants are faced with extensive globalisation of information on sexuality through mass media (e.g. radio, movie, TV, books and the Internet) and many young people learn about sexual matters through these media as these issues are prohibited from family discussion [31]. The process of urbanization and the increasing influences of western culture affects many population groups, but especially the young, and are also seen to be responsible for contending prevailed traditional customs. Increase in premarital and extramarital sex is seen by many as a consequence of the induction of western norms and values [32]. There is some evidence that young people who have access to the internet and satellite TV possess more permissive attitudes toward premarital sex [33]. A study carried out in the USA provides strong evidence that sexual content on television, by and large, encourages adolescents to initiate sexual intercourse [15]. Previously, a study carried out among border towns of Nepal documented that those watching television regularly were 51% more likely to be engaged in risky sexual behaviour than their counterparts who rarely watched television6. However, one has to be aware that there might be a socio-economic bias as poorer people in Nepal are less likely to possess a TV, less likely to have completed their education and more likely to live a more conservative and traditional life. Perhaps, parents may be able to reduce the effects of sexual content by watching TV with their young children and discussing their own belief about sex and the behaviour portrayed in TV shows. In addition, mass media itself could also be a positive means of disseminating sexual health promotion information to young people in Nepal. There is evidence that mass-media is also an effective medium to impart vital information on issues related to sex and sexuality. Hennink and colleagues34 found that young men and women identified media as the most prominent sources of information on sexual development.

Findings of this study indicate that many young people of Nepal are very curious towards the issues related to sex and sexuality. They also have a belief that sex-play gives maximum pleasure. Young people also have opportunities to watch pornographic films to fulfil their desires to learn about these issues. It becomes more feasible particularly when young people stay away from their home or have less parental supervision. A similar pattern was found in other geographical settings too. For example, Abraham [35] reported that boys tend to watch pornographic films in a friend’s residence or at a video parlour. A study of Chinese women found that they gain information about opposite sex and sexual intercourse from pornographic magazines and videos, and that young boys and girls watch such videos together and which is often followed by sexual activities [36]. Although in contemporary western societies, pornography is much more accepted and sexual images are part of fashion, art and advertisements and music videos [37], Nepal’s legislation prohibits all kinds of pornographic movies and materials [31]. The trading of pornographic movies is considered as an offence and it is prohibited for screening publicly in cinemas. Many nude posters used for publicity of such movies can be seen in public places [38]. This also highlights poor actions by authorities towards such activities. Some argue that watching pornographic movies may lead to developing certain desires among viewers which at times lead to serious crimes. Porn movies may also encourage people to indulge in unsafe sex [38]. Young people should be better informed towards the consequences of unsafe sex. Particularly, more information on the risk of STIs and unwanted pregnancies provided to young people would encourage them to engage in safe sexual behaviour.

Our findings also reveal that young people of Nepal not only receive information from peers but often receive pressure from their friends regarding sexual activities. Young people also like to imitate their peers' activities, usually as an adventure. These findings are similar with previous studies carried out in other Asian countries. For example, a study conducted in Thailand showed that 40% of young boys participated in sexual activities because they also wanted to be as experienced as their friends [39]. Another study conducted in Nepal [7] also reported that peer pressure was a possible reason for premarital sex among college students of Kathmandu. This suggests that sex and relationship education programmes through trained peer educators40 are needed to disseminate information to young people toward safe sexual behaviour. Perhaps school and college would be the ideal settings for imparting sexual and reproductive health education and life skills to a large number of adolescent and young people [41,42].

Many young people in Nepal also grab premarital sexual opportunities through opposite sex friendship and romantic relationships. Dating practice in Nepal has become common and many young people meet in isolated places with their dates [43]. It was frequently reported that dating encourages premarital sex. These findings emphasize that dating and romantic relationship issues should also be incorporated in young people’s sexual and reproductive health issues. Similarly, most participants reported the importance of personal characteristics such as appearance (e.g. fashion and beauty) for the initiation of sexual activities. Mostly male are more concerned with the appearance of girls. A previous study in India showed that 'time pass relationships' are generally initiated and cultivated by boys, and lasted only until they had sexual intercourse with the girl [35]. Feelings of love, fondness and intimacy were also reported as reasons for having premarital sex which is similar to the findings reported in other geographical settings [44]. Alexander and colleagues [45] found that young women agreed that refusing to the partner’s proposal of sex would hurt their chances of marrying them, suggesting that young people seem to believe their opposite sex friends on the foundations of sex. More focus is needed on negotiation and decision making skills.

Fear of pregnancy, societal pressures, parental expectation and trust are key factors which discourage young people from engaging in premarital sex. However, there was a general agreement among participants that greater awareness about sexual and reproductive health issues and better availability of contraceptives in most areas of Nepal has encouraged young people to engage in premarital sexual relationships. Many young people of Nepal view premarital sex as a normal phenomenon. Most participants reported that it is okay to have sexual relationships if reliable contraceptives are used to prevent pregnancy - as found elsewhere46. Similar views were found among Scottish young women. They considered sexual intercourse as a normal activity for adolescents [47].

Education and the mass media have changed young people’s attitudes and belief towards premarital sex. A previous study has also shown a positive association between education and premarital sex [7]. In addition, young people do trust their sexual partners and are ready to take any risks for it. There is evidence that if young people believe their partners and trust them not to be infected they may not perceive themselves to be at risk [48,49]. This evidence suggests that awareness alone is not a sufficient measure to encourage safer sex in young people.

Financial pressures may play a large role in influencing male and females to instigate premarital sex, and perhaps even more so for young girls who need economic supports to fulfil their basic needs. These issues have been particularly well-described for sub-Saharan Africa [27,50]. Sex can also be a way of getting money and gifts from boyfriends. For example, a study carried out in Africa found that many girls like to make boyfriends because these men tend to give money and gifts [51]. Indeed, most girls in Nepal lack ownership of any property and are deprived of economic activities. Mostly men control the finance within households, which contributes to women’s economic dependence on men [52]. Perhaps, for these girls, poverty and the lack of alternative methods of generating income may often result in the decision to initiate sexual activities as they need income to support themselves. This highlights that economic issues should be addressed in order to improve young people’s sexual and reproductive health.

Finally, although sex-related issues are not openly discussed in Nepal; many participants in this study actively discussed them contrary to the preceding generation. Perhaps the media attention towards sexual and reproductive health programmes has encouraged them to take part actively in the study. In addition, training of the same-sex researchers and confidentiality assured to the participants may also have contributed to getting a good response from the participants. This qualitative study was conducted in some urban and rural areas of two districts of Nepal, making it difficult to generalise the findings for other areas of Nepal. This study has also included a fairly heterogeneous group and therefore, these findings should be interpreted cautiously.

Acknowledgements

We would like to thank the participants and facilitators in Nepal for their contribution to this study. We acknowledge the insightful comments of Mr. Puspa R Pant, University of the West of England, Bristol on a draft of this paper. This study was supported by a grant to the first author from the University of Aberdeen and the Carnegie Trust for Universities of Scotland.

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