SEXUAL BEHAVIOUR AND PRACTICES: A STUDY OF MALE CLIENTS OF FEMALE SEX WORKERS IN MUMBAI

Transcription

1 SEXUAL BEHAVIOUR AND PRACTICES: A STUDY OF MALE CLIENTS OF FEMALE SEX WORKERS IN MUMBAI S.K. SINGH, SUDIPTA MONDAL AND NIDHI SHARMA Introduction Sexual activity in humans is an instinctive form of physical intimacy. It is performed for the purpose of biological reproduction, spiritual transcendence, expressing affection, and/or for pleasure and enjoyment (often termed as sexual gratification ). In fact, human sexuality is shaped by cultural and historical contexts. In interactions with their culture and society, people learn and internalize various expressions of sexuality. 1 Sexual behaviour of human beings has been studied from different perspectives. In the context of the HIV/AIDS epidemic, the study of sexual behaviour of sub-populations has assumed greater importance. It is more so in India since, it witnessed the spread of HIV infections mainly through the sexual route, except for the north east. In fact, paid sexual networks have been critical in fanning the momentum of the epidemic in India. In the context of the HIV/AIDS epidemic, the important areas that need to be studied under sexual behaviour include sexual debut, multiplicity of partners and context, and condom use behaviour. A thorough understanding of varied aspects of sexual behaviour especially paid sex is necessary to get a comprehensive picture of the epidemic. A variety of factors may influence the rate of sex work related transmission of HIV including, prevalence of HIV infection among sex workers and their clients, availability, acceptability and use of appropriate condoms, frequency of unprotected sex, prevalence of other behaviors like sharing of unsterilized drug injecting equipment, economic status of sex workers and clients as well as their working conditions and migrant status. 2 S. K. Singh, Associate Professor, Department of Mathematical Demography and Statistics, Sudipta Mondal, PhD Scholar and Nidhi Sharma, International Institute for Population Sciences (IIPS), Mumbai. Vol. 55, No. 2, December

2 Sex work has long been associated with the spread of sexually transmitted infections. By definition sex work involves transactions between vendors and purchasers. The latter clients, vastly outnumber the women and girls who provide sex for money. Even so, much of the popular discussions of the health implications of sex work have always, rather myopically, concentrated on the role of the vendor (seller) as the possible source of infection while largely ignoring the role of those who pay for sex. 3 Not only just in terms of transmission of infection but rather the whole gamut of psychosocial and behavioural research on sex work has been heavily concentrated on sex workers. Although there is considerable interest in men paying for sex for devising effective prevention strategies, there are few studies that allow an estimation of how many men actually buy sex and know their behaviour and factors leading to those behaviours. In United Kingdom, a national study of sexual attitudes and lifestyles was carried out in over 19,000 households in which 1.8 percent of men reported having paid for sex in the last five years. 4 In contrast, a national telephone survey of Swiss males estimated that 12 percent of men aged between 17 and 30 had paid for sex. 5 A study of the sexual behavior of over 2,000 Dutch military personnel on detachment in Cambodia during June 1992 revealed that 45 percent had sexual contacts with prostitutes or the local women. 6 A study carried out in Lisbon found that of the 200 men surveyed, 25 percent began their sexual life on the basis of contacts with a prostitute. 7 It is clearly not possible to make general statements about the number of men buying sex on the basis of these studies. Nevertheless, it would appear that a significant number of men are paying for sex, and further that this varies enormously across different areas. Another London study, found that men felt it was easier to ask a prostitute rather than their regular sexual partner, to perform certain sexual acts. 8 A North American study observed that the illicit nature of buying sex from a prostitute was in itself a source of enjoyment for the clients. 9 In India studies on actual clients are few and far between. A study by Bhattacharya,10 based on 100 semistructured interviews conducted with clients of brothel based female sex workers in Pune in Maharashtra, found that the clientele differed in terms of their socio-economic status. Of all the clients interviewed, more than 83 percent were preponderantly local residents. Nearly half of the sample reported regular use of alcohol. The other important finding was that condom use was common among clients. Mumbai, also known as the AIDS capital of India houses a large number of sex workers and migrants also constitutes a large chunk of the client. Today, Mumbai s red light areas, have a variety of sex establishments catering to varied practices, which is available 24/7. Despite the AIDS epidemic, the supply of sex workers to Mumbai s red lights district continues. The present study attempts to throw light on various aspects of the male clients of female sex workers in Mumbai. Most of HIV prevention interventions focus mainly on hotspots (reaching/targeting female sex workers at locations where they solicit sex). However, clients of sex workers, who are an important bridge between high risk (mainly those who have multiple sexual partners) and low risk (primarily having monogamous sexual relationships) populations remain beyond the purview of organized programmatic responses. It is primarily due to the complexities of their elusiveness and unwillingness to admit their paid sexual behavior. It ultimately makes them highly inaccessible to most of the direct interventions or research. However, it seems to be quite important 40 The Journal of Family Welfare

3 to understand their attitude, behaviour and practices, especially looking at the transitional opportunities and structure of sex work in India, specifically in big metro cities like Mumbai. Within this context, it is necessary to study the attitudes, practices and behaviors of clients of sex workers for appropriate designing, planning and implementation of programs aimed at arresting the rapid pace of the spread of HIV infection. This paper examines the sexual behaviour and practices of male clients of female sex workers. It details the onset of sexual debut, their experience of engaging in sexual relationship with different partners, paid and unpaid, including the same-sex behaviour. Furthermore it captures risk perception and condom use with different partners and sexual acts as well as barriers to condom use. Methodology This study is based on primary data collected from male clients available in different sex access points (place of solicitation and not necessarily place of encounter) in Mumbai. The primary survey carried out from December 2006 to January 2007 used both qualitative as well as quantitative techniques of data collection. Time Location Cluster Sampling (TLCS) was used to recruit clients from various sex access points across Mumbai. Time-location sampling is used to sample a population for which a sampling frame cannot be constructed but locations are known at which the population of interest can be found, or for which it is more efficient to sample at these locations. It was decided to recruit clients only from brothel-based sites and dance and service bars in Mumbai. The overall refusal rate was quite high among clients recruited from brothels (25.7%) as against among those recruited from bars (6.7%). Out of 25 red-light areas in Greater Mumbai, three red-light areas namely, Kamathipura, Ghatkopar and Turbhe Store were chosen for recruiting clients for the study, to capture the new and old type of brothel areas with greater geographic representation. From the three selected red-light areas, a total of 11 clusters (nine lanes of Kamathipura, the entire area of Ghatkopar and Turbhe Store red-light areas) were selected. For each brothel-based sex work cluster that operated every day of the week, a total of 42 Time-Location Clusters were generated each representing any one of the 3 time-slots of a day (12.00 Hrs to 18:00 Hrs, Hrs to 22 Hrs, and Hrs to Hrs), any of the seven days of the week (Monday, Tuesday, Wednesday, Thursday, Friday, Saturday, and Sunday), and either of the two weeks of the survey that took place for brothel based sites (Week 1 and Week 2). For 11 sex work clusters, a total of 462 clusters were formed in the sampling frame. From 462 clusters, a total of 30 clusters (20 from Kamathipura and 5 each from Ghatkopar and Turbhe Store) were randomly chosen for the study to recruit a fixed number of 5 clients from each cluster. Ultimately, during the two weeks of the survey, only 104 clients out of the maximum possible 140 could be interviewed from the brothel based sites. For recruiting clients from bars, Mumbai was divided into 4 clusters, Chembur, Santacruz, Juhu and Turbhe based on the geographic spread. From these clusters, a list of 128 bars was prepared. For 128 bars, a total of 8,960 time location clusters were created after adjusting the survey period of 4 weeks in bars. Finally, 50 clusters were randomly chosen to recruit 5 clients from each cluster. At the end, only 196 clients out of the maximum possible 210 clients could be interviewed. In total, 300 clients were interviewed using semi-structured interview schedule. The qualitative part of the study was organized in two phases. At the initial stage, the aim was to know more about the ambience in which sex work takes place. Vol. 55, No. 2, December

4 For this purpose a number of interviews with local key informants were conducted to gather comprehensive insights into community level information. Basically the organizational heads and their staff who were in charge of implementing various intervention programs in the redlight districts were the primary source of information and they acted as key informants as well. Altogether 15 key informant interviews were conducted. During the quantitative survey an effort was made to identify some dynamic and garrulous respondents for the purpose of conducting in-depth interviews in order to have detailed understanding of clients attitude, sexual behavior and practices. As a result, 20 in-depth interviews were carried out. These interviews were especially important to seek answers of some of the underlying reasons for practiced behaviors and practices. Besides these key informant interviews and in-depth interviews, the qualitative techniques included field observations and field notes. Results and discussions Sexual Debut In the overall sexual experiences, sexual debut seems to play a major role. Several studies have been undertaken to link sexual debut with other behavioural and physiological traits including delinquency, sexual performance or even chances of acquiring STI. One study has found that condom use in sexual debut enhances the subsequent protective behaviors with less sexual partners. 11 Another study has shown that knowledge of STI is more among males with a later age at sexual debut. 12 The present study has made an effort to enquire the age at first sexual encounter with females and males. The results show that the average age of first sexual encounter with a female was 18.9 years. The minimum reported age was just 13 years and the maximum was 30 years. Nearly half of the clients have reported to have attained sexual experiences with the opposite sex before completing 18 years. On the other hand, it is interesting to see how age of sexual debut changes between the two groups of clients under studybrothel-based and non-brothel-based. TABLE 1 Mean age of study clients at the time of sexual debut with female partners by their place of recruitment Clients Age (in completed years) Mean Min Max N Brothel-based Non-brothel-based Total Table 1 show that the mean age of sexual debut with a female partner is higher in case of non-brothel-based clients than brothel-based clients. Table 2 shows that this difference is significant between the two groups of clients. Age of sexual debut significantly differs between brothel-based clients and non-brothel-based clients. Perhaps it reiterates the fact that sexual debut is often influenced by background characteristics of the individual in addition to social and cultural factors. TABLE 2 Influence of client's category on age in sexual debut (ANOVA table) Source of Sum of Degree of Mean variance squares freedom square F p Between groups <0.05 Within groups Total The present study also tried to seek similar information in case of samesex behavior. During the community observation, especially in one lane of Kamathipura, it was found that a number of male clients were also looking for sexual interaction with hijras (eunuchs), suggesting that same sex behavior among these male 42 The Journal of Family Welfare

5 clients is not uncommon. Moreover, during the qualitative phase of the present study, there were references made by the study clients of their homosexual experiences. This study has found that the average age was around 20 years when clients were initiated and their first sexual experience with another male, which is slightly higher than their entry. The minimum age was the same 13 years and the maximum age was a little higher at 32 years. However, only 17 percent of the study clients admitted to have sex with another male or hijra. First Sexual Activity Sexual experiences are collected step by step and coitus is merely one of the several experiences in this regard. 13 Sexual expressions include hugging, kissing, pressing breasts, looking at female genitals, masturbation and vaginal or anal intercourse. Often, many of these nonpenetrative sexual acts precede sexual intercourse or again many in sexual TABLE 3 relationships may perform only these nonpenetrative sexual acts. Not necessarily one individual experiences all these acts with a single sexual partner. This study has tried to find out the nature of sexual partners with whom the study clients first indulged in different forms of sexual acts and the person who took the initiative for these maiden acts. Table 3 shows that the majority of study clients had initiated the sexual act with un-paid partners. Among the unpaid partners, girl friends were the most common, followed by other girls with whom they shared casual relationship. Other girls included classmates, casual friends, neighbors and relatives. Most of the maiden non-penetrative sexual acts have been performed largely with un-paid sexual partners. Except looking at the female genitalia and `vaginal intercourse, less than five percent of the clients reported that they indulged in these activities with sex workers. First sexual act, relationship with sexual partner and self initiated sexual act Paid Sexual Types of unpaid Sexual Partners Partner Self- Type of first sexual acts (sex workers Girls in casual Girl initiation and bar girls) relationship Friend Wife (%) (%) (%) (%) (%) Hugging Kissing Pressing breasts Looking at female genital Vaginal intercourse Anal intercourse (N = 33) * * For anal intercourse the majority of the partners were either male friends or colleagues In the words of one respondent aged 35, working in a blue collar job, Jab main navi kaksha me tha, main meri bhabhi ke ghar gaya tha. Bhabhi ke choti behen X jo rishte me meri sali lagti thi, unke saath kafi ghulmil gaya jise samajik manyata prapt thi. Main wonhan do hafta raha is dauran hum dono kafi nazdik agaye jo ant me sexual intercourse me badal gaya. u samay aisa laga sayad hum dono saadhi bhi kar le lekin yea ho nehi paya. (When I was a student of standard IX, I went to my sister-in-law's house and stayed for almost two Vol. 55, No. 2, December

6 weeks. During my stay, I came very close to Ms. X, younger sister of my sister-in-law and I spent considerable time with her that eventually resulted into intimate relationship, which was socially acceptable in view of our relationship. In fact, our intimate relationship ended with sexual intercourse with mutual consent. We thought of getting married but it did not happen like that). Although these are the first sexual acts, perhaps mostly prior to their entry into the paid sexual network, it is observed that these clients still have sexual ties with unpaid partners other than their spouses, increasing the potential of spreading the HIV infection manifold. The data also suggests that the first time partners for anal sex are mostly un-paid. Almost 94 percent of the clients who responded to this question said that they had anal sex with casual male partners that mostly included colleagues, friends and classmates. Anal sex in heterosexual relationship seems to be much lower. However, the study could not deal with this issue in depth. It was felt important to not only learn about the first sexual partners but also to gather information on who initiated the first sexual acts. Condom use behaviour of these clients during sexual debut was important information that was not collected as part of this study because of recall lapse, instead current condom use behaviour was included. Sexual behaviour with male partners Homosexual behaviour of these primarily heterosexual clients perhaps connects two different sexual networks together, thereby fuelling the HIV epidemic further. Although it is very important to study same-sex behaviour of the clients, the present study does not focus on this aspect as it requires a separate in-depth study. This study only touches upon a few salient and critical nuances around same-sex behaviour of clients that have a direct bearing on the HIV/AIDS epidemic. As mentioned earlier, the presence of homosexual behaviour is low but not uncommon. Only 17 percent of the study clients have admitted to have ever indulged in sexual encounters with other men. The data also shows that the age of debut for homosexual experience is a little over 20 years, which is slightly higher than their first sexual encounter with sexual partners of the opposite sex. This study has also found that over half of these clients (56%) who admitted to have had homosexual encounters, their most recent partners were their friends. Only about 10 percent have reported to have bought sexual services from male sex workers in their last sexual encounter. For 13.5 percent of the study clients, the last homosexual partner was casual or unknown and a little over one-fifth reported their last partner as other, mainly their colleagues. The important aspect that emerges is the overwhelming presence of casual un-paid sex in case of same sex behavior. The study did not capture whether these sexual exchanges were experimental, situational or just an alternative to heterosexual ties in the absence of sexual partners of the opposite sex. The data shows that only a little over one-third of the clients used condoms during their last homosexual encounter. Most (66%) of them did not use condoms. Sexual behaviour with female partners The three most recent sexual partners excluding wife, a large majority (74%) stated that at least one partner was either girl friend or other girls with whom they shared casual sexual ties. Only 25 percent reported that all the last three female sexual partners were sex workers. When the last sexual partner is segregated, it was found that nearly one-fourth of them had sex with either their girl friends or other girls among non-brothel-based clients and it was always sex workers for brothel-based clients. Probably it was biased by the fact that most of the brothel-based clients were recruited for the study when they came out of the brothels after sex (Table 4). 44 The Journal of Family Welfare

7 Further analysis, revealed that nearly 47 percent of the clients who reported to have had last sex with sex worker also had the second last sex with sex worker and almost the same proportion (48%) had the last and third last sex with sex workers (Table 4). However, more than half of the clients whose last sexual partner was a sex worker reported that their second last sexual partner was either a girl friend or other girls. In this analysis, wife has not been included. On the other hand, only 35 percent of the clients whose last sexual partner was a girl friend, have reported to have their second last sexual partner as a girl friend but more than 65 percent have reported either a sex worker or other girls. This is true in case of the last and third last partners and also almost the same trait is observed in all sorts of partners. TABLE 4 Percentage distribution of clients by their last three female sexual partners Last Sexual Second Last Third Last Partner Sex Worker Girl Friend Other Girls Sex Worker Girl Friend Other Girls Total Sex Worker Girl Friend Other Girls Total This indicates that the study clients not only visit sex workers but also have sexual ties with girl friends or other girls. In the words of one of the clients in Kamathipura, main idhar chup chup ke ata hoon, meri girl friend ko pata tak nahi hain agar usko pata chal gaya toh who pucca mere saath dosti tod degi (I come here secretly. My girl friend has no clue about it. If she comes to know, she will definitely leave me). Another in-depth interviewee also told, meri ek girl friend hain, uske saath ek do bar sex bhi kiya hai, lekin humesha mauka nahi milta hain isliye idhar ana padta hai (I have a girl friend and we had sex once or twice but it is difficult to find regular opportunities to be physically intimate with her. Hence I prefer to come here). In answer to a direct question on sexual ties with other girls/women, who are not paid for sex, a large proportion (81%) stated to have sex with them and 47 percent have sex with them at least once a month. Most of these girls are either neighbours, colleagues and in some cases relatives. Experience of paid sexual encounters In the study of sexual behaviour, it is very important to learn the sexual behaviour and practices of the clients of sex workers. It is particularly of interest to find out the reasons why men go to sex workers and buy sex, and who introduces them to commercial sex. Clients were asked about the reasons (based on clues found in the qualitative phase of the study) why they go to sex workers. They preferred to choose multiple reasons for this. The most frequently stated reason was to fulfill their sexual fantasy (59%). However, it is not clear what is exactly meant by sexual fantasy. The same question was dealt with in the post-quantitative survey in which some respondents stated that they wanted to perform certain sexual acts which they do not usually perform with their un-paid sexual partners. Some clients confessed that they had lost interest in their wife and some felt that their wives do not understand what they want and have become less caring about their sex lives. Around 36 percent of the respondents cited that since their friends go there, they also visit sex workers (Figure 1). Other reasons were their feeling of loneliness (34%) and sexual urge (30%) and peer pressure. Vol. 55, No. 2, December

8 Apart from these reasons, the other reasons given were absence of their wife or girl friend, and that visiting sex workers is a sign of manliness (2.7%). Qualitative analysis revealed that a few respondents attached masculinity with this sexual behaviour. It was difficult to tease out the critical factors which drive some men to buy sex from sex workers as there is no control group of men with similar background characteristics but still prefer not to visit sex workers. In a survey of 1,225 men and women on paid sex, men who had ever paid for sex (clients) were compared with men who had never paid for sex (non clients) on 13 demographic and sexual history measures. Only four factors significantly differentiated clients from non-clients. Clients were significantly older, less likely to have been educated beyond high school, less likely to report having a regular partner in the past 6 months, and more likely to report that their most recent sexual encounter was with a casual partner. Clients of sex workers reported that the major reason for paying for sex was to satisfy their sexual needs, followed by the belief that paying for sex was less trouble and that it would be entertaining. A factor analysis of the reasons for visiting sex workers identified three factors labeled as Ease, Engagement, and Arousal. In the present study, arousal in the form of excessive urge for sex emerged. However, the other two factors, ease and engagement, were not studied carefully in the quantitative survey. It figured in the qualitative study when some clients tried to articulate that it was much easier for them to buy sex than develop casual sexual relationship with girls as there is no accountability. To quote one bar-based respondent, sex workers ke pas jane se koi jhamela nahi hai..jab man hota hai to jao nahi to na jao..koi commitment nahi hai..achha nahi lagta hai to dusra ladki ke pas ja sakte hai (Going to sex workers is much easier. Whenever you feel the urge, you can go to her, there is no commitment in it. The day you stop liking her, you can go to another girl ). To have a better understanding of their social network, clients were asked with whom they first visited sex workers. Nearly 63 percent of the study clients said that they went with their friends and another 29 percent went alone. This suggests that group behaviour and peer pressure play an important role. This is corroborated with another study on risky sexual behaviour of men The Journal of Family Welfare

9 The study also throws light on since when the clients have been visiting sex establishment to buy sex in Mumbai. All clients did not have the experience of visiting both these type of venues. Out of 300 clients, 150 had ever visited redlight areas for sex, which is 46 more than brothel-based clients recruited in the study. On the other hand, 196 bar-based clients participated in the study, but 236 clients had the experience of visiting bars (Table 5). TABLE 5 Duration of visit to red light areas and bars Red-light areas Bars Duration N =150 N =236 (%) (%) More than 5 years Between 2 to 5 years Between 1 to 2 years Between 6 to 12 month Between 1 to 6 months Less than one month Most of the clients have been visiting either red-light areas or bars since less than five years. The average age of the study clients was around 32 years, suggesting that their entry to the commercial sexual network is much later than the age of sexual debut, which was about 19 years of age. The frequency of visits to red-light areas and bars varied significantly. Nearly 23 percent of the clients have said that they visit red-light areas once in a month, whereas 40 percent visit bars once in a month. Around 35 percent of the clients visit brothels once in three months and a little over 26 percent visit bars once in three months. A multivariate logistic regression was used to understand the factors that might have significant bearing on the frequency of their visit to sex workers. However, except for age no other variable had a significant influence on the frequency of visit. This may be captured through qualitative insight or through a larger sample size. In paid sex, money is being transacted. Clients need to buy services by paying money. The cost of various sexual services varies as the typology of sex worker and the other accompanying facilities change. It is almost common knowledge that bar girls demand more money than their brothel-based sex workers. Even in the same typology, the cost changes based on attractiveness, age, ethnicity and other factors. The study results show that on an average, clients spend Rs.210 for every paid sexual encounter with a brothel-based sex worker. It is five times costlier in case of a bar girl. In brothels, also the rates vary significantly. The reported minimum amount spent is as low as Rs.10 and the maximum amount as high as Rs.3,000. The corresponding amounts for bar girls are Rs.160 and Rs.7,000 respectively. The qualitative study shows that girls who provide escort services or work as call girls charge mostly the highest amount of money from their clients, followed by bar girls and other sex workers. Even among other ordinary sex workers, the rates of homebased, privately operating sex workers is more than their brothel or street-based counterparts. Finally, based on the qualitative findings, one inference can be drawn that the more a sex worker is shorn of a typical sex-worker-look with gaudy dress and make-up, the more is the cost of her sexual services. Equally, the more invisible a sex worker is, the higher is the charges for her services. Sex and Alcohol Use Alcohol use was found to be rampant among the study clients. Nearly, 95 percent of the respondents reported taking alcohol. However, it is of pertinent interest to study alcohol use in the context of sexual encounters since many research studies have stressed the fact that the influence of alcohol is a strong deterrent to safe sexual practices. In a recent study, 7 it was reported Vol. 55, No. 2, December

10 that alcohol use prior to sex is significantly associated with inconsistent condom use, and condom use is significantly lower when both the partners are intoxicated. The present study finds that alcohol consumption is common among the study clients during their sexual contacts. It also shows that consumption of alcohol varies with the type of sexual partner (Table 6). TABLE 6 Alcohol consumption during last sex and type of sexual partner Type of partner Paid sexual encounter with Use of Alcohol During Last Sex Brothel-based Sex Worker Unpaid sexual encounter with N Bar Girl Girl Friend Other Casual Female Partner Wife Clearly, alcohol consumption is high during sex with paid sexual partners as compared to unpaid partners. Among unpaid partners, the level of alcohol consumption varies. The lowest reported use of alcohol during last sex is with his wife. Only 17.5 percent of the currently married respondents said that they consumed alcohol before last sex with their spouse. It was found to be higher with other casual female partners (44%) and girl friends (31%). Anal Sex A number of studies have covered anal sex behavior especially among men who have sex with men (MSM). By and large, anal penetration is the most common form of sexual activity performed by MSM. However, even in the heterosexual context where presumably anal encounters are low, studying anal sex is important as unprotected anal sex increases the risk of acquiring HIV and other STIs and evidently more risky than peno-vaginal encounters. Anal penetration often leads to the tearing of rectum tissues that makes the sexual partners more vulnerable to pass on sexually transmitted infections. Besides, awareness about safe sexual practices related to anal and oral sex is inadequately addressed. Since anal or oral sex is safe from pregnancies, the use of condom is often neglected. Condom use for dual protection (HIV and pregnancies) requires attention. Realizing the importance of this issue, the present study made an effort to understand how common is the practice of anal sex with different types of partners. However, since this issue is sensitive and intimate the various nuances of anal sex with the study clients could not be probed. Table 7 shows that the overall practice of anal sex is low. It is marginally higher with paid sexual partners than with unpaid sexual partners. Socially desirable responses cannot be eliminated altogether, considering the taboo associated with anal sex. Indulging in anal sex may be one of the fantasies, as stated earlier, one of the prominent reasons for visiting sex workers is to fulfill sexual fantasies, various small scale research studies conducted by various agencies running on-going HIV/AIDS prevention intervention programs across the country suggests that clients of female sex workers often ask for anal sex. TABLE 7 Experience of anal sex and type of partner Type of partner Paid sexual encounter with Ever Had Anal Sex Brothel-based Sex Worker Unpaid sexual encounter with N Bar Girl Girl Friend Other Casual Female Partner Wife The Journal of Family Welfare

11 Condom use behaviour There is compelling evidence that consistent and correct use of condoms can be effective in preventing the transmission of sexually transmitted pathogens including HIV. In the absence of complete cure or a vaccine, condom use is perhaps the single most important factor that can help prevent HIV transmission. Since the majority of HIV transmission is through unprotected sex, the HIV prevention intervention effort in India veers around the issue of increasing condom use among sex workers and their clients. The large scale HIV prevention intervention programmes along with mass media campaigns throughout the country, has helped in increasing condom use during commercial sex encounters. However, condom use among commercial sex workers and their regular unpaid partners remains a challenge, as also the use of condoms within marital relationships, especially when the male partner cohabits with multiple partners and/or buy sex. Perhaps, the limitation of intervention data is manifold. Most of the programmes use this as an indicator of success. Moreover, female sex workers reached through the programme are often asked the same question on condom use, also most of the research on heterosexual commercial sexual behaviours involve female sex workers as respondents. They often suffer from research fatigue. Under such circumstances, the tendency to provide more socially desirable answers cannot be ruled out. Due to intensified efforts of intervention programmes, the onus of using condoms rests heavily on sex workers and, their clients, in most cases, are absolved of their responsibilities. As fewer studies are conducted with the clients of female sex workers, they mostly remain outside the purview of research thus, creating a vacuum of information, especially when the resistance to condom use mostly stems from these men who buy sex from female sex workers. The present study attempts to fill this void by providing clients perspective on condom use which can help redesign strategies towards promotion of condom use. In the wake of the HIV/AIDS epidemic, clients are expected to be more aware on condom use and its benefit. Mass media and mid media are increasingly educating people which includes men. When study clients were asked whether they usually carry condoms when they go for paid sexual encounter, only 28 percent respondents were positive, 45 percent responses was sometimes, and more than 25 percent said that they did not carry condoms when they pay for sex. Carrying condoms may not be important as in most of the cases condoms are easily available with sex workers. Nonetheless, it suggests risk-perception of these men. It is no denying that those who carry condoms in most of the cases exhibit higher risk perception towards STI/HIV than those who do not. Often sex workers say that they always insist their clients to use condom. A similar question was asked to male clients on who usually insists on condom use. The data suggests that nearly 65 percent of the study clients themselves insisted on condom use during sexual encounters with sex workers. Vol. 55, No. 2, December

12 Clients were also asked about their source of knowledge for correct use of condoms. Although one response was intended, most of the clients preferred to provide multiple sources. Figure 2 shows that the primary source of knowledge about correct condom use was friends/ relatives. Sex workers and NGO workers were equally the next source of information on correct condom use. Perhaps this is due to the presence of many intervention programs in the study area. Interestingly, nearly 35 percent of the clients have acknowledged that they have also (since multiple sources were cited) learned from the sex workers they visited. Although condom use is assumed to be a panacea for preventing sexually transmitted infections, its breakage or slippage during use, however, can reduce the effectiveness of this method leading to a higher chance of transmitting infections via vaginal, anal or oral sex. Many studies have examined condom breakage and slippage rates in developed and developing country settings among diverse populations including married couples, male homosexual couples, female and male sex workers and STI clinic users. Rates of condom breakage and slippage vary widely across these studies, from four percent to more than 12 percent breakage per 100 sex acts in developed country settings, and considerably higher in developing ones. 16 In the present study, an attempt was made to understand the rate of condom breakage among these clients. The clients were asked in their last 5 encounters (to avoid recall lapses), how many times they experienced condom breakage. No distinction was made between paid and unpaid sexual encounters. The result shows that 17 percent of the study clients experienced at least one condom breakage in their last five sexual encounters. Condom breakage perhaps depends on multiple factors. Sungwal et al., found that female sex workers in Thailand reported of condom breakage with multiple clients, younger clients, sex after midnight, and high intensity (rough) sex. Now, we will examine the actual reported use of condoms by these study clients. Clients were asked to report condom use in their last sex with various types of partners. 50 The Journal of Family Welfare

13 Table 8 clearly shows that condom use reported during last sex encounter was high among commercial partners as compared to non-commercial partners. It was found to be the lowest with their spouse. Only 5.6 percent clients who were currently married said that their last sexual encounter with their wife was protected with a condom. Use of condoms seems to be less also with girl friends (23%) and other unpaid female partners (44%). However, it is encouraging to note that condom use with sex workers is at least comparatively higher. TABLE 8 Percentage distribution of clients by their use of condoms in the last sex by type of partners Type of partner Paid sexual encounter with Used Condom during Last Sex Brothel-based Sex Worker Unpaid sexual encounter with N Bar Girl Girl Friend Other Casual Female Partner Wife Due to higher use of condoms in commercial sex and very low use with spouses, no effort was made to understand the variation in condom use with sex workers and wives. However, a logistic regression analysis was performed to understand the predictors of condom use with casual female partners. It has been found that the level of education of the study clients seems to have a significant bearing on condom use. The higher is the level of education, higher is the chance of using a condom. In case of girl friends, education also does not seem to have a significant role in explaining the variation in condom use during last sex. Perhaps due to the smaller sample size and higher refusal rate, it is difficult to use regression analysis to ascertain the predictors of condom use. It is rightly a challenge for any HIV/ AIDS prevention intervention effort to increase the level of condom use in casual sexual relationships and also within conjugal sexual bond. In the present study, a set of statements around condoms and its use was canvassed to have an idea about clients attitude towards condom use. The statements mentioned in Table 9 can broadly be sub-divided into three categories. TABLE 9 Percentage distribution of clients by their agreement to various statements around condom and its use Statements Percentage Agreed Condom reduces sexual pleasure 47.0 Now-a-days sex workers always insist 87.7 on condom use during sex If one is too familiar with a sex worker, 51.7 she does not insist less on condom use If one pays little more, sex workers 49.0 agree to have sex without condom Condoms often break 67.7 Not all condoms are reliable and good 67.3 Condoms do not give full protection 48.7 from STI/HIV infections Safer to use multiple condoms 64.0 The first part is about the general attitude towards condom use and just one statement (the first one in the table) is used. The second part consists of three statements basically to throw light on condom use in commercial sexual relationships. Most of the studies collect information from sex workers and as mentioned earlier, responses from sex workers might suffer from biases. Responses from clients will be helpful to the on-going HIV/AIDS intervention programs in addressing the barriers of condom use. It seems more likely that clients response on these questions will have less bias. The third set of statements basically deals with their risk perception and their level of satisfaction about the available quality of condoms. Vol. 55, No. 2, December

14 It is well documented through various studies that lower use of condoms is often linked to the perceived notion of many users that it considerably reduces the level of sexual pleasure. Perhaps this oftquoted statement is once again reaffirmed in this study as a little less than half of the respondents (47%) agreed to the statement that condom reduces sexual pleasure. Due to the onslaught of the HIV/ AIDS epidemic in the study area, a number of intervention programmes have been implemented mainly among sex workers and bar girls in Mumbai. These programmes are helping to bring a positive change towards condom use. In this regard, clients were asked whether sex workers always insist that condoms must be used. Majority of the clients (88%) answered positively to this question. However, close to half of the study clients also agreed that if a client is close to the sex worker, chances are that she will not insist on condom use. Moreover, nearly 49 percent of these clients also agreed with the statement that if one is ready to pay extra money, the sex worker may agree to indulge in unprotected sex. It is important to understand how clients perceive condoms and its efficacy. Nearly, 67 percent of the clients agreed with the statement that condoms may often break. They seem to have less reliance on condoms. They also agreed to the statement that not all condoms are reliable and good. In the qualitative phase, it was observed that some clients have preference for certain brands of condoms. Apart from this personal choice, the more important aspect is to understand their risk perception. In fact, the use of condom is perhaps a sign of their increased level of risk perception generated mostly out of the fear of acquiring HIV and the increased level of awareness on HIV/AIDS. Nearly 48 percent of the study clients agreed that condoms do not provide full protection from STI/ HIV infection. As a result, they adopt various coping strategies as was evident in the qualitative phase of the study. A few respondents stopped visiting brothels believing that brothel-based sex workers are more likely to have HIV infection, increasing their chances of acquiring STI/ HIV, despite condom use. Again, some adopt various other measures like washing sex organs immediately after sex. One brothel-based respondent told, kaam ho janeke turant baad main daru se mera ling dho leta hoon (immediately after the sex act, I wash my penis with alcohol). On the other hand, some prefer to use multiple condoms for better protection. In the present study, 64 percent of the clients agreed that using multiple condoms offer more protection than a single condom. References 1. Lewin, B., Fugal-Meyer, K., Helmius, G., Lalos, A., and Mansson, SA Sex in Sweden. On the Swedish Sexual Life, Stockholm, Sweden: National Institute of Public Health. 2. UNICEF The state of world children, New York, Oxford University Press, USA. 3. McKeganey, N., Barnard, M Sex Work on the Streets: Prostitutes and their Clients. Open University Press, Buckingham, Philadelphia. 4. Johnson et al Sexual Attitudes and Lifestyles. Oxford: Blackwell Scientific Publications. 5. Hausser et al Evaluation of the AIDS Prevention Strategy in Switzerland. Third Assessment Report, ( ), Lausanne: Institute University de medicine Social et Preventive. 6. Buma et al Sexual behavior and sexually transmitted diseases in Dutch marines and naval personnel on a United Nations Mission in Cambodia. Genitourinary Medicine, 71: Amaro, F. et al Sexual behavior in the city of Lisbon. International Journal of STD and AIDS, 6: Day, S. et al Sex work and risk of HIV: Male partners of female prostitutes. British Medical Journal, 307: The Journal of Family Welfare

15 9. Holzman, H., Pines, S Buying sex: The phenomenology of being a John. Deviant Behaviour: An Interdisciplinary Journal, 4: Bhattacharya, S Brothels and brothel clients in Pune city. In: Verma et al. (Eds) Sexuality in the Time of AIDS: Contemporary Perspectives from Communities in India, Sage Publication, New Delhi. 11. Taraneh, S., Katherine, S., and King, H Association between condom use at sexual debut and subsequent sexual trajectories: A longitudinal study using biomarkers. American Journal of Public Health, / AJPH Genuardi, F.J., Boker J.R., and Oh M.K Age at sexual debut predicts sexually transmitted disease knowledge among males, American Pediatric Society 104th annual meeting and Society for Pediatric Research 63rd annual meeting; 1994 May 2-5; Seattle. 13. Jakobsen, R Stages of progression in non-coital sexual interactions among young adolescents: An application of the Mokken Scale Analysis, International Journal of Behavioral Development, 21 (3), Mondal, S Migration and risk of HIV/AIDS: An empirical study, Rajat Publication, New Delhi, ISBN Zablotska, Iryna B.A, Gray, Ronald H.A, Serwadda, D.B., Nalugoda, F.B., Kigozi, G.B, Sewankambo, N.B., Lutalo, T.B., Mangen, F., Wabwire, B., Wawer, M.C Alcohol use before sex and HIV acquisition: A longitudinal study in Rakai, Uganda. Epidemiology and Social AIDS. 20(8): , May 12, Albert, AE., Warner, DL., Hatcher, RA., Trussell J, and Bennett, C Condom use among female commercial sex workers in Nevada's legal brothels. American Journal of Public Health 1995; 85: Vol. 55, No. 2, December