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Dhaka, Bangladesh

HIV/AIDS/STI Prevention

Dhaka, Bangladesh

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Analysis of Family Planning / HIV/AIDS Integration Activities within the USAID Population, Health and Nutrition Center
- by ww.advanceafrica.org

In Their Own Words:
The Formulation of Sexual and Reproductive Health
Behaviour Among Young Men in Bangladesh

Shivananda Khan
Sharful Islam Khan
Paula E. Hollerbach

Existing research on adolescent males and their sexual and reproductive health has been largely focused on knowledge, attitudes, and practices, but not on the determinants of their behaviour that could positively affect their health. Socialisation processes and societal pressure on young boys and adolescents to prove their manliness shape young men’s attitudes to feel strong and immune to disease, to accept risky sexual behaviour, early initiation of sexual behaviour, and multiple partners. Within many cultural contexts, young males are expected to be strong, competitive, goal-oriented, and are pressured to prove their manhood through sexual encounters (Barker, 2000). The urgent question that needs to be asked then, is how do we reach young preadolescent and adolescent males with sexual and reproductive health information and programme interventions before they become sexually active?

At this early stage, they can be more effectively influenced to understand and practice safer sexual practices, including delaying sexual initiation, reducing the number of sexual partners, engaging in alternative non-penetrative sexual activity, and using condoms. They can also be encouraged to develop greater respect and sensitivity towards girls and women. Finally, they can be encouraged to utilise sexual and reproductive health and family planning services throughout their life.

New research data are needed to gain greater insight into how young men’s normative patterns of sexual attitudes and behaviour are influenced from their early preadolescent years on. The data would help in understanding the images that young males create regarding their own masculinity and sexuality. Such data would also provide insight into what impact these images have on young men’s personal risk behaviours, the meaning given to them, and the manner in which these images legitimise and reinforce their actions.

To better inform the research framework, methodological approach, and instruments for the qualitative formative research study, the CATALYST Consortium prepared a Country Background Paper, analysing and presenting the most recent HIV/AIDS/STI epidemiological and behavioural survey data, as well as sexual and reproductive health interventions undertaken in recent years with young men in Bangladesh (Brockman et al., 2002).

Following review and discussion of the situation, a framework for formative research was developed in Dhaka, Bangladesh, in consultation with those responsible for the funding, technical assistance, and management of the study.

CATALYST-FUNDED RESEARCH

A study was subsequently conducted by Bandhu Social Welfare Society in Bangladesh under the guidance of Naz Foundation International with funding and technical support from the CATALYST Consortium, USA and the U.S. Agency for International Development. The study design was developed through collaborative discussions between Naz Foundation International, the CATALYST Consortium staff and a CATALYST consultant, Doortsie Bracken, and USAID Mission staff in Dhaka based on a background paper written by Brockman et al. (2002). Mr. Shivananda Khan, M.A. and Chief Executive of Naz Foundation International, developed the study guides. Dr. Sharful Islam Khan, a medical doctor with a masters degree in Health Social Science, Mahidol, Thailand, recently received his Ph.D. in Anthropology from the Faculty of Community Services, Education and Social Sciences, Edith Cowan University, Perth, Australia. He is a Research Investigator with the Social and Behavioral Science Unit, ICDDR,B: The Center for Health and Population Research in Dhaka, Bangladesh. Together, the two investigators completed the data analysis. In addition, Dr. Sharful Khan served as Master trainer for those responsible for conducting the interviews and focus group discussions. Paula E. Hollerbach, Ph.D., Evaluation Advisor to the CATALYST Consortium, provided technical assistance in the formulation of the study guides, advice on participatory research techniques, informed consent procedures and IRB review and approval, and editing. Shivananda Khan, Sharful Islam Khan, and Paula Hollerbach wrote the report.

PURPOSE OF THE STUDY

As the world’s population of young people aged 10-24 years old reaches 1.7 billion, the largest cohort of young people in history, increasing attention has been focused on providing youth with the skills necessary to make healthy reproductive decisions and the services required. Programs and services for youth, like those for adults, often focus on young women, and do not adequately address the needs and roles of young men. Furthermore, programs often fail to address the influence that male and female gender roles and inequities have on sexual decision-making. Because the behaviours and values of boys and young men affect the health and well being of girls and young men, reproductive health programs are likely to have greater impact with the constructive involvement of young men,

Adolescence is a developmental stage of tremendous biological, social, and cognitive change. Attitudes and values about “correct” behaviours are learned and internalised. For boys, these can include viewing girls and women as sex objects, condoning coercion to obtain sex, and equating sexual prowess and multiple sexual partners with manhood. Youth is also a time when homophobic attitudes and behaviour form, often deriving from efforts to exaggerate masculinity and reject traits that are perceived to be feminine. These attitudes have led to human rights abuses and violence frequently perpetrated by young men.

Yet, the formative years of adolescence are also the time when young men may be most receptive to more equitable concepts of masculinity and to new and more informed perspectives regarding their roles and responsibilities in reproductive and sexual health and intimate relationships. As a result, programs need to include attention to young males—as early in the socialization process as possible—to ensure that boys are exposed to gender equitable values and norms, and positive and respectful attitudes and behaviours towards women and sexual minorities are reinforced.

The principal lens in which this qualitative study approached the investigation of these norm-forming processes was through “sexual and social scripting.” Sexual and social scripts are interactional models of social expectations. They are the plans people have for what they are doing and what they are going to do, as well as the devices for remembering what they have done in the past. Learning and applying a sexual script is part of growing up in any culture and society. Social and sexual scripts are rarely the outcome of a systematic and conscious learning process, but rather an accumulation of responses to the multiplicity of cues operating within one’s culture and society (Gagnon, 1990; Gagnon and Parker, 1995; Gagnon and Simon, 1973; Simon and Gagnon, 1986). Examining sexual and reproductive health behaviours from the perspective of social and sexual scripts allows the researcher to organise and link together what people think, what they do, and how they are affected by the sociocultural contexts in which they live. Viewing sexual conduct as “scripted” also gives the behaviours a narrative quality in which conduct is composed of events that are ordered in time.

Briefly, the study was designed to explore the processes that operate in the formation and reinforcement of the knowledge, attitudes, and behaviour of young men. This norm forming process was viewed through sexual and social scripting, an interactional model of social expectations, where learning and applying a sexual script is part of growing up in any culture and society. These scripts are an outcome of an accumulation of responses to a multiplicity of cues operating within the culture. Based on this theoretical approach, the study contextually analyses the development of young men’s sexual scripts, and the roles played by influential socialising agents in their development.

This study generatedqualitative formative and contextual data to better understand the sexual and social scripts through which normative sexual attitudes and sexual and reproductive behaviours among young men aged 10-24 are influenced and formulated from early adolescence on. The study also sought to understand the impact of education and recent migration to Dhaka on the construction of masculinities by exploring the formation of social and sexual scripts on three levels:

  • Individual and personal (attitudes, emotions, beliefs, and behaviour)
  • Interactional and social (interpersonal behaviours and the impact of socialising agents)
  • Cultural and religious (gender arrangements and expectations).

In particular, the study examined closely the influential roles that socialisation agents play in constructing norms regarding sexual behaviour, young males’ masculine and sexual images regarding themselves and others, and their sexual and reproductive health beliefs, attitudes, and behaviour.

Issues Investigated in the Study

Themes and aspects of masculinities and sexualities explored in the study with respondents included:

  • Gender awareness and understanding
  • Friendship and intimacy
  • Sexual knowledge and awareness
  • Sexual messages
  • Sociocultural and family expectations
  • Sources of knowledge
  • Impact of knowledge on sexual and reproductive behaviours

For parents and guardians,
the themes were:

  • Being a parent
  • Children growing up
  • Friendship and intimacy
  • Cultural, social, and family expectations
  • Knowledge and information
  • Impact of knowledge on children’s behaviour

For socialising agents, the themes were:

  • Current behaviour of young men
  • What do they learn and from whom
  • Social and cultural expectations
  • Knowledge and information
  • Impact of knowledge



Demra District, Dhaka

OBJECTIVES

For HIV/RH programs to reach young men with appropriate information and interventions to guide their understanding of sexual health and avoid risky sexual behaviours, it is important to first understand the processes that operate in the formation and reinforcement of such knowledge, attitudes, or behaviours. However, empirical data on these normative processes are generally lacking. The specific issues investigated with the study populations are listed below.

Specific objectives of the study were as follows:

  • Explore the social constructions of masculinities and sexualities of male adolescents
  • Understand male adolescent decision-making regarding sexual behaviours and gender relationships
  • Explore the cultural, social, and family expectations that impact upon male adolescents and the manner in which they shape their personal and social behaviours
  • Discover who are the socialising agents of male adolescents and the manner in which male adolescents are socialised
  • Discover what impact these processes have on sexual and reproductive health and gender power relationships and behaviours.

RESEARCH METHODOLOGY

All 290 respondents resided in the thana of Demra in Dhaka. Demra represents a mixed-use thana. Commercial interests, including factories, markets, and street vendors, and residential housing, including slums and middle-class housing coexisted in this thana. Demra houses a range of social support and health services, hosting a significant population of recent migrants and literate and illiterate young men.

Cohorts of boys in three age groups were studied. Cohort A was comprised of 64 boys from the general population of males (GPM) who participated in eight participatory research groups. They were divided into two groups aged 10-12 (Cohort A1) and 13-15 (Cohort A2) to allow grouping the respondents closer to one another in cognitive and verbal abilities and mental and emotional development. Information was elicited through qualitative participatory research techniques using drawings, story telling and discussions, role playing, and body mapping. Cohort B was comprised of 88 young men aged 16-19. Cohort C was comprised of 88 young men aged 20-24. Both cohorts were further subdivided into two groups, one recruited through the MSM networks and one recruited from the general population of males (GPM). Although the study focused on the development and reinforcement of the normative and predominant masculinity and sexuality in Bangladesh, respondents were also drawn from different male-to-male sexual networks in the study area.

Kothi is a self-identifying label for those males who may feminise their behaviours (either to attract “manly” male sexual partners and usually in specific situations and contexts), and who state that they prefer to be sexually penetrated anally and/or orally. Any male, who is sexually penetrated, even if his behaviour is not feminised, is referred to as a kothi. Kothis state that they do not do sex with other kothis. They may also be married to women. The term panthi is a kothi label for any manly male. A panthi is by definition a man who penetrates, whether it is a woman and/or another male. They may also be married to women. Most male-to-male sex in Bangladesh appears to follow this pattern, where a kothi is not defined as a man, which enables the penetrating partner to still see himself as manly.

Parik is a kothi label for the “husband” of a kothi. The parik may also be married to a woman and/or do sex with women. Hijra is a self-identified term used by males who define themselves as “not men/not women,” but as a “third gender.” Hijras cross-dress publicly and privately, and ritual castration may be part of the hijra identity. Many provide blessings to newborns or to newlyweds. However, begging and commercial sex work are additional sources of income.

This study is not statistically representative of all male adolescents in Demra. Using snowball techniques, respondents preselected other respondents, and contacts provided by Bandhu Social Welfare Society networks in the thana of Demra were used to identify males who have sex with males. A thanais a defined district within a city encompassing many neighbourhoods. The three age cohorts were further segmented by different educational levels (none to four years of education completed, in comparison to five or more years) and length of residence in Dhaka (less than six months or six months or more).

Interviews were also conducted with 20 parents and 18 socialisation agents who participated in different FGDs, including community leaders, religious teachers, and purveyors of traditional medicine referred to as kobirajs. Finally, interviews were also conducted with men of different sexual identities, including married kothis, married panthis, and pariks, and hijras. An anonymous census of sexual behaviours was administered to 24 respondents aged 20-24 who were interviewed and 12 respondents from small subsamples of pariks, married panthis, and other MSM (married kothis, hijras).

Each respondent was coded according to cohort and variable. Interviews were first transcribed into written Bangla and then translated into English for analysis, while focus group discussions (FGDs) and data gathered through the participatory research approach were analysed from the original Bangla data sets.

Because of the nature of the data being collected, where translation into English could be problematic (the translations were quite poor grammatically), and the analysis was completed in Bangla. It was decided to conduct a thematic and content analysis of the data using a manual approach. This approach was facilitated greatly by the utilisation of thematic topics already developed for data collection to guide the data analysis. Initially, each FGD report and interview transcript was read several times to get a sense of its meaning and content. Statements made were analysed for content, meaning, and significance, according to specific cohort, theme, and subtheme. Commonalities and differences were then recorded on a spreadsheet, which permitted comparisons within the cohort and recognition of commonalities and differences across cohorts.

KEY FINDINGS AND RECOMMENDATIONS

The study was designed to understand the impact of educational level and recent migrationto Dhaka on the socialisation process and constructions of masculinities among adolescents. However, these intervening variables had no discernible impact on the attitudes, behaviours, and beliefs of different age cohorts. Age differences also did not greatly influence the overall pattern of information and the issues raised, other than the heightened awareness of sexuality among the respondents in Cohort A2, B, and C. Findings will be reported by theme, and differences found by age group and gendered identity will be noted.

The key themes studied with adolescents included: gender awareness and understanding, friendship and intimacy, sexual knowledge and awareness, sexual messages, sociocultural and family expectations, sources of knowledge, and impact of knowledge on their behaviour.

Parents were questioned on issues pertaining to being a parent, growing up, friendship and intimacy, family, social, and cultural expectations, knowledge and information, and the impact of knowledge on children’s behaviour. Other socialising agents were also questioned on the behaviour of young men, social and cultural expectations, and knowledge and information.

The key findings for each theme are discussed below, as well as the programmatic recommendations, which were developed in consultation with the study team members and representatives from USAID/Bangladesh and 14 agencies who participated in a dissemination meeting on the findings from the Formative Study on Sexual and Reproductive Behaviour Among Young Men in Bangladesh, which was held on March 11, 2003.

Gender awareness and understanding

By the age of five, boys are fully cognisant of the dominant masculinity, gender roles, and gendered differences between boys and girls (clothes, mannerisms, space, language, etc.), which are accepted as biologically and religious ordained. (“Itis Allah’s will.”) The dominant masculinity is perceived as active, assertive (if not aggressive), and powerful, with a penetrative sexuality. Femininity is perceived in opposition: Females are submissive, domestic, and obedient to the significant males in their lives, who could be the father, older brother, or husband. Girls and women are not seen to have a separate, autonomous existence but are subject to their control. This belief is reinforced by the social, cultural, and religious expectations expressed and reinforced by family members and other socialising agents. By age 12, sexual roles and expectations are understood and accepted. Sources of information about gender roles and gendered behaviour include observation while growing up, parents, elder siblings’ and friends’ circumcision rites, and religious teachers.

Religious (both Islamic and Hindu) messages promote conflicting attitudes towards women. On the one hand, they can be seen as dangerous because of their capacity to seduce men, as they are supposed to be more sexual than are men. However, women are also seen as weak and vulnerable, need to be protected from men’s sexual gaze, and therefore need to be covered and made “invisible.” Both beliefs, that Bangladeshi women are weak and women are sexually voracious, co-exist.They therefore need to be controlled and supervised, and their access to men not directly related to them should be policed. Females are thus domesticated, invisibilised, and not usually seen in public spaces after sunset. Economic circumstances may be forcing a change in this attitude with the growth of the garment industry, which employs predominantly young female workers. However, there is still strong disapproval of women in public spaces.

Proof of manliness is characterized by a number of traits: Behaving and looking like a man; having love affairs with girls and talking about them to their friends; stating that they can last a long time doing sex and talking about sex; competing with friends on penis size, erections, and masturbation; watching pornographic movies; body-building, keeping fit, and demonstrating fitness; joining a gang, engaging in criminal or terrorist activities, and carrying a weapon; teasing girls; and being a father. Young men feel the need to demonstrate the dominant masculinity among their friends and within other social groups. This is reinforced through dress style, action, work, language, and behaviour involving penetrative sexual prowess (or at least its verbal expression) with females, and can escalate to sexual harassment (eve-teasing) of young girls and feminised males.

Some young men, by the age of seven and as they mature, prefer to exhibit what are deemed to be feminine behaviours and practices that are demonstrated through mannerisms, dress styles, and other “girlish” behaviours. Such dissonance with socially expected male behaviours creates family tension and disapproval for having crossed gendered boundaries and usually leads to violence and abuse, as the older male members try to force conformity on the young boy. These occurrences and the inner conflicts that arise become a source of pain, loneliness, and low self-esteem leading to disempowerment, marginalisation, and social exclusion as they grow up. These feelings eventually lead to self-damage, a sense of hopelessness, fear or shame, risky sexual behaviours, and even suicidal tendencies (Bondyopadhyay and Khan, 2004).

Kothi/hijra males identify as a “gender apart,” neither male nor female. This renders these males more vulnerable to sexual violence and HIV infection and STIs, as receptive anal sex is the preferred choice for the sexual act. These gendered differences are further reinforced between the age of 8 and 14 by sexual experiences with other older males and socialising with older kothis and hijras in their locality. School dropout is a common experience. Kothis-identified males believed that they were more handicapped than women because they have no social roles. Pariks and panthis identify as men. However, the vast majority of them typically marry women, since marriage and reproduction of sons are perceived as compulsory.

Recommendations

1.1 A comprehensive education and sensitisation programme for young men regarding gender disparities and inequalities, masculine violence and sexual harassment should be developed and implemented. This programme will need to be designed for different age groups, educational levels, and employment statuses and delivered in a variety of ways. These could include school and college educational programmes, street theatre, drama, cartoon booklets, youth newspapers, kiosks for youth in recreational sites, radio, television, and cinema.

1.2 A range of confidential support and counselling systems should be developed for feminised males (kothis and hijras), and other MSM, that would include sensitising male counsellors and health providers to their needs and supporting and promoting the services that already exist. Appropriate agencies with technical knowledge and expertise will need to be identified to provide training resources and support such initiatives. Bandhu Social Welfare Society is such an agency and provides a national community-based HIV/AIDS and sexual health service primarily to marginalised and stigmatised males in several cities.

Friendship and intimacy

Friendships in Bangladesh are defined within the context of strong male-to-male bonding with social and family sanction and approval, where affection and physical closeness is primarily between males. Male-female friendships outside of marriage, however, are strongly disapproved of and actively discouraged by both family and society. In a gender-segregated society, male-to-female friendships are seen as love affairs, if not sexual. Such friendships, even when they are nonsexual, are kept secret from family and neighbours. However, personal friends may actively encourage and support such friendships as proof of one’s manliness, believing them to be love affairs. Co-existing with these attitudes and behaviours is the social expectation that boys and girls should see and treat one another with respect as though they were brother and sister.

Young men have very few opportunities outside the classroom to meet young women socially and mix freely with young women. Consequently, they lack the social skills to deal with young women outside of members of their immediate family and do not fully understand their feelings, emotions, or desires toward women. Given the need to express sexual prowess and the urgent need for discharge as components of a demonstrative masculinity, this often leads girls and women to be sexually objectified and may strongly influence young men’s behaviour towards girls and women whom they casually meet, leading to eve-teasing and sexual harassment.

Eve-teasing is a term used to describe harassment of girls and women (and feminised males) by boys and men. Such harassment can take the form of making sexually suggestive comments or gestures, ogling, groping, or forced touching of the body or clothes of a girl or woman. Eve-teasing is often rationalised as normative and normal group behaviour, a perceived consequence of the victim’s suggestive behaviours, and a way in which to prove manliness to others. All respondents have heard of, seen, or participated in such teasing. All kothi-identified respondents reported being subjected to a form of eve-teasing as well. All of them reported that their first sexual encounter was “forced sex,” and that they regularly experienced such encounters, usually by groups of boys.

Male-to-male friendships, however, are actively supported, and casual sexual encounters between male friends as well as sex between masculine males and feminised males is quite common and accepted, even though this behaviour may be socially disapproved. All respondents in the general population of males reported having male friends who do sex with other male friends. This was not seen as sexual friendship, but as “friends helping friends” achieve discharge based on personal sexual needs. All kothi-identified males reported that they usually do sex with their masculine friends, but not with other kothi friends or with female friends. They also reported that they knew of many masculine males who do sex with their manly friends. They did not consider this to be normal behaviour since both males were manly.

Recommendations

2.1 A peer education system based on friendship networks, where young men are trained to share information and tolerance and gender sensitisation strategies with their friends could be established through neighbourhood groups, clubs, and centres. Peer counselling, as a tool to address a range of masculinity concerns, should also be part of this programme. This will require a range of recruitment strategies, training tools, effective oversight, and monitoring and evaluation procedures.

2.2 Many effective programmes have already been developed and can be adapted and replicated. Initially, a comprehensive review of current literature, tools, and resources will need to be reviewed, and a range of discussions instituted with young men (and women) to develop the framework of the programme, ensuring that the information they need is incorporated. Parents and other socialising agents will also need to be included in the design of such programmes.

Sexual knowledge and awareness

The median age at which respondents first “had sex with another person” (sex undefined) was 13 for the general population of males in Cohort C, with a range from 12 to 17 years of age. MSM (kothi and hijra-identified males) usually have their first sexual experience much earlier than other males, usually during preadolescence. The range is 7-14 years with a median age of 11. Kothi respondents believed that this was because they were “girlish” in their behaviours, could mix in public spaces with other males, and were therefore more easily available. For feminised males their first sexual experience usually occurred during early adolescence with an older male, while for the masculine males it primarily followed the onset of puberty, either with a female or perhaps with another male. For GPM respondents, their feelings were generally positive and an affirmation of being a man. For the majority of kothi-identified males, pubertal experiences were negatively perceived, because of their contraindication to their inner sensibilities.

Knowledge of reproductive and sexual health is very limited and tends to reinforce myths, misinformation, or contradictory information. A range of sexual beliefs and myths are held, which often leads to significant psychosexual problems and concerns regarding penile size, semen loss, nocturnal emissions (nightfall), puberty, and sexual intercourse. In contrast, penetration is perceived as a source of sexual power. Friends and kobirajs reinforce these concerns when they speak of masturbation as producing a weak and thin body with semen waste that leads to impotency. Semen and blood are linked, and, therefore, to masturbate is to weaken the body through what is perceived as blood loss. Youth are also informed that nocturnal emission is a disease that needs to be cured. Thus, the belief that masturbation and nocturnal emission cause illnesses may readily lead young men to early penetrative sexual encounters to avoid such illnesses. Nonetheless, masturbation is a common practice that often generates a deep sense of shame and guilt. GPM respondents generally believed that male-to-male sex was a bad experience, but understandable. Kothi-identified respondents defined male-to-male sex as different from male-to-kothi sex. Typically, male-to-male sex was deemed as “not normal.”

Male-female premarital and extramarital sexual behaviours appear to be common in Demra. For normative males these sexual practices are deemed to be mainly the result of sexual need and “body heat,” not as an outcome of desire for another male. Thus, female sex workers, cooperative females, needful male friends, or kothi-identified males are accessed for “discharge-based” sex. At the same time, male-to-male sex within the dominant masculine framework also appears to be quite common. The median age at first sexual experience is youngest for members of Cohort C MSM (10 years) and all MSM (11 years), and postpubertal for Cohort C GPM (13 years) and pariks and married panthis (14 years).

Despite the early sexual experiences of many adolescent males, the appropriate age for sex for boys was generally perceived as higher (18-25) among GPM cohorts than among MSM cohorts (16-25). Younger boys in Cohort B cited 17-18 years as an appropriate age for girls, while older boys in Cohort C suggested 17-21 years. It was believed that boys should delay marriage until they are able to support their families economically, whereas girls should marry when they are capable of bearing healthy children and taking care of a family. Where adolescent males are experiencing sexual encounters, whether with a female or with another male, regular condom use is low. Condoms are seen as a family planning method, while access to water-based lubricants is also very limited.

In the case of girls, virginity is seen as a possession related to honour, shame, and the prestige of the girl and her family. This virginity involves behaviour, dress, and attitudes, as much as actual sexual experience. Girls must be virgins before marriage. However, young men accept that for boys this is not possible, even though it remains a social and religious expectation for their behaviour.

Recommendations

3.1 Sex education packages, perhaps within the broader context of “Life Skills,” should be developed or adapted which cover sexual anatomy and biology, male and female emotional and physical relationships, growing up, living healthy lives and nutritional advice, marital life and responsibilities, and appropriate health-seeking behaviours.

3.2 These education and information packages need to be designed for specific age groups as a phased system and delivered in culturally sensitive ways that are able to reach both literate and non-literate young men. Programmes need to be developed in a participatory fashion involving parents and young people. In order to begin addressing these needs, the Health Communication Partnership (HCP) based at Johns Hopkins University Bloomberg School of Public Health, with funding from USAID/Bangladesh and UNICEF/Dhaka has launched the “Know Yourself” Adolescent Reproductive Health (AHR) Communication Program through the Bangladesh Center for Communication Programs. The ARH program began with earlier support through USAID’s “Focus on Young Adults” and “Population Communication Services” projects and activities and included the development of an Adolescent Reproductive Health toolkit. Expansion is now taking place under the USAID-funded HCP with additional funding from UNICEF. An important feature of the program has been the intensive involvement of a coalition of partners, the Adolescent Reproductive Health Working Group, that has continued to work together and expand in order to carry out the necessary formative research for, and guide the process of development of, a set of communication materials to address many of the priority adolescent issues and problems revealed.

3.3 Many curricula, such as those already being taught in India and Egypt, originally developed by the Centre for Population and Development Activities (CEDPA), could be adapted to be appropriate for the Bangladesh context. They combine such curricula with training in specific vocational skills that will promote employment in later life.

3.4 Technical support should be given to a nongovernmental organisation in Dhaka (perhaps in Demra Thana) with funding to develop and test a free telephone help-line service that can offer anonymous and confidential advice and information from trained counsellors. The service would address questions on reproductive and sexual health, as well as issues on sexual abuse, rape, and psychosexual concerns, and educational and career options. These hotlines for young men and women, which are already operating and successful in various cities in Pakistan, for example, should be manned by trained health professionals, such as physicians and nurses. This will require a specialised training curriculum to cover the range of issues identified in this study for the training of counsellors and peer educators.

3.5 Arange of appropriate NGOs involved with young men should be identified and supported to deliver such confidential advice and information services.

3.6 See Recommendation 1.2 under Gender awareness and understanding.


Sources of knowledge and sexual messages

The youngest boys talk about computers, sports, movies, and comic books. Young men talk about a variety of topics, including sex, prostitutes and brothels, girl friends, cinema, television, and pornographic movies. They also discuss news events at the time, ways of getting a job and earning money, education, the transition from school to work, politics, and at times, terrorism, carrying weapons, and drug use. Kothi-identified young men primarily discuss fashion, music, cinema, dance, dealing with parents, and finding a

“husband.”

Parents provide primarily knowledge on social and religious rules, and obligations of marriage, but they are not approached for information on sexual and reproductive health. However, the primary sources of knowledge are older friends, pornographic videos, health magazines, and kobirajs.

Pornography is a primary source of information on sexual behaviours and practices of adolescent males after the age of 12 or 13, due to the low cost and easy access to videos and videocassette players. They are accessible in both rural and urban areas, andmost young men have seen at least one such video by the age of 14. However, the media also play a strong role in confirming gender and sex stereotypes, portraying female sex workers and “bad women” as the vectors of HIV/AIDS/STIs. Satellite television, books, sex magazines, and cinema also provide information.

Kobirajs, seen more in rural areas than in urban areas, are still important for low-income groups (less popular among the educated and middle classes); they are purveyors of inexpensive medicine and advice on sexual and reproductive health. They are not trained, their remedies have often been shown to be “quackery,” and their knowledge and advice regarding sexually-focused problems are based on myths and misinformation. They are inexpensive and easily accessed, usually plying their trade in crowded areas, bazaars, and market places where men congregate. The decline in their popularity is probably attributable to growth in the electronic media and print press, along with many cheaply produced handbooks on sex and sexual health.

Recommendation

4.1 Parents, community and religious leaders, and kobirajs also need sensitising and access to appropriate information and knowledge. While specialised training and educational packages can be adapted from already existing materials or developed to provide accurate information, different forms of media and formats will need to be used for parents. These could include print and visual media, leaflets, and brochures, as well as street dramas. Such forms of education will need to acknowledge different levels of literacy and the concerns that many parents, religious leaders, and others have with regard to any explicitness in sexual and reproductive health information.

4.2 See Recommendation 1.1 under Gender awareness and understanding.

4.3 See Recommendation 2.1 under Friendship and intimacy.

Sociocultural and family expectations

Sociocultural and familial expectations of young men reflect behaving like a man, fulfilling family, social and religious obligations and duties, being a good son, having respect for elders and showing obedience to parents. Adherence to Islamic traditions and obligations, attaining a good education, working hard, earning “good” money, avoiding “bad people and habits,” being patriotic, getting married and having a son are all primary family and social expectations for young men.

Socialising agents such as parents, community leaders, religious teachers, and kobirajs all had opinions, attitudes, and perceptions which have meaning within their respective occupational and social contexts. Religious teachers tend to be conservative and traditional and hold Islamic positions on reproductive and sexual health behaviours. In this study they were opposed to any form of sex education. Community leaders tend to be more liberal and accepting in their attitudes towards adolescent behaviours. Kobirajs supported their own need to market their cures and advice but still held to the dominant sex/gender system within this context. Thus, boys go to them for advice and seek treatment for a range of psychosexual concerns and problems.

Parents also expressed a high level of distrust of their neighbours and their possible negative impact upon their families. Parental concerns and expectations reflect the social turmoil and rapid social changes that they perceive that Bangladeshi society is experiencing. Rapid urbanisation, globalisation of the market economy, satellite television, political challenges, and a growing youthful population who face a lack of job opportunities and overcrowding, rather than good living conditions and privacy, highlight these concerns.

Along with this view, however, there is also a growing open attitude particularly among mothers. While fathers were opposed to sex education for their sons, mothers believed that their sons should receive some reproductive health education “at the right age.” Mothers also appear to have a growing sense of hopelessness and fear for their son’s future in the face of the challenges that Bangladeshi society is experiencing.

Despite the social and religious expectations that parents, community leaders, and religious teachers should play primary roles in the lives of young men growing up, there is a deep conflict between these expectations and reality. For many young men, while it is the mother or both parents whom they highly respect and would listen to for advice, they frequently find it very difficult to accept and follow that advice. For them life outside the home and inside the home are two separate and distinct worlds. More often than not, parents do not know much about their sons’ world. However, parents on the whole appeared to be satisfied with their sons’ behaviour, but were extremely concerned about the possible influences of the world outside the home on them.

Young men typically listen more to their friends as their primary source of information and knowledge, particularly with regard to sex, recognising that such talk and behaviour are against the expectations of their parents and society, and are therefore kept secret. Following preadolescence, the young person’s peers carry much more influence and power in a culture of non-visibility of socially unacceptable behaviours.

Recommendation

5. See Recommendation 1.1 under Gender awareness and understanding. It is essential that these materials be adapted to make them appropriate to sensitise parents and other socialising agents.

Impact of knowledge

Young men have very poor knowledge of sexual and reproductive health. What knowledge exists is primarily myths and incorrect information, which generate a range of psychosexual concerns and fears around penile size, masturbation, nocturnal emissions, puberty, and sex. At times these fears can be traumatic, generating fears of illness and the need for unnecessary treatment. This leads to significant vulnerability and may promote risk sexual behaviours and early penetrative sex.

When asked what information boys and young men want to know, respondents replied: sexual and reproductive health; puberty and growing up; marriage, marital life, and birthing; nutrition and healthy living; STIs/HIV/AIDS; how to do sex properly to ensure satisfaction; masturbation, nocturnal emission, and other psychosexual concerns; and legal and religious issues around marriage, divorce, and other issues. Recognising their lack of knowledge and information on sexual and reproductive health, young men wanted accurate, open, explicit, and easily accessible information on these issues. However, they were unsure who would be the most appropriate person to deliver such information and the way in which it should be delivered.

While parents and other socialising agents recognised the need to provide good reproductive health information so that young men are prepared for marital life and its responsibilities, they were deeply concerned about its content, explicitness, and mode of delivery. Parents also recognised the threat of STIs to their sons’ health. However, they were unclear on what the content of such health information should be and who or what should deliver this information. Mothers felt radio would be the best because of the absence of images, while fathers recommended that nongovernmental organizations and leaflets provide “education.” While fathers were opposed to reproductive and sexual health education for their sons, mothers believed that their sons should receive some education “at the right age.”

Recommendations

6.1 Organize workshops, seminars, and discussions to bring together stakeholders to address the emergent HIV/AIDS epidemic in Bangladesh, by focusing on masculinity and its impact on sexual and reproductive health.

6.2 See Recommendation 1.2 under Gender awareness and understanding.

6.3 Sexual and reproductive health clinical services that specifically address the needs of adolescent males should be developed through partnerships with adolescent health programmes, projects that work with youth or street children, or those provided through services in local community centres.

6.4 STI management and treatment staff should be sensitised and trained to understand MSM health issues, provide nonjudgmental advice on medical and psychosexual concerns and follow protocols for appropriate STI screening, diagnosis, partner referral, and confidential treatment.

6.5 Women of all ages need to be sensitised to the variety of gendered identities and the implications of MSM behaviour for their own reproductive health, through family planning counsellors.

The challenge will be how to effectively address questions of dominant masculinity and manliness that encourage sexual harassment and violence, not only against girls and women, but also against feminised males, and secondly, how to improve access to appropriate sexual and reproductive health information for young men in a traditional, often conservative culture and increase the health-seeking behaviours of young men. Presentation styles and mediums will need to be cognisant of the fears and concerns expressed by parents and other socialising agents, and the social, political, and religious realities in Bangladesh and appropriately pre-tested.

To this end, a range of workshops, seminars, and discussions should be organized that bring together a range of stakeholders from educational, economic, and health sectors, including the commercial sector, the government, and NGOs. The purpose will be to initiate processes of collabouration and joint initiatives to address and finance programmes that focus on issues of masculinities and their impact upon sexual and reproductive health and promote better understanding and cooperation to mitigate the emerging HIV/AIDS epidemic in Bangladesh and promote health-seeking behaviours of young men who are particularly vulnerable, their female partners, and children.

An initial step should entail the continued collabouration with the Adolescent Sexual and Reproductive Health Working Group to develop strategies, messages, and programmes around which sexual and reproductive health pilot project interventions can be designed, such as school-based SRH programmes, youth help lines with confidential advice for medical personnel, and life skills curricula for out-of-school youth. It is essential that these respond to identified needs as perceived by the young men themselves.

It is recognised that the specific recommendations identified offer broad-based approaches to promote the reproductive and sexual health response to male adolescent needs identified in this report. A comprehensive programme focused on the sexual health needs of young men will need to be developed to provide a package of sensitisation, information and educational programmes, training, and referral to clinical support, involving young men, socialising agents, and collabouration with a range of sexual and reproductive health service providers and family planning programme counsellors.

Such a programme should not be seen as separated or isolated from other development and empowerment agendas in Bangladesh. Thus, poverty alleviation schemes, rural development, women’s literacy and microcredit programmeswill need to be seen as natural allies and partners for such a holistic approach.

REFERENCES

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Barker, G. What about boys? A literature review on the health and development of adolescent boys. Geneva: World Health Organisation, Department of Child and Adolescent Health and Development, 2002.

Bondyopadhyay, A. and S. Khan. Against the odds. Naz Foundation International. Available at http://www.nfi.net/ under NFI publications/NFI reports and other documents.

Brockman, S, Z. Rionda, O. Hernández, and P. Hollerbach. Reaching young men in Bangladesh: The epidemiological, social and behavioural context for developing effective male-focused sexual and reproductive health programs. Unpublished paper prepared for USAID/Bangladesh. Washington, DC: The CATALYST Consortium, 2002.

Gagnon, J.H. The implicit and explicit use of the scripting perspective in sex research, Annual Review of Sex Research 1990 1: 1-43.

Gagnon, J.H. and R.G. Parker. Conceiving sexuality. In Conceiving sexuality. Edited by R.G. Parker and J.H. Gagnon. New York and London: Routledge, 1995.

Gagnon, J.H. and W. Simon. Sexual conduct: The social sources of human sexuality. Aldine, 1973.

Simon, W. and J. Gagnon, Sexual scripts: Permanence and change, Archives of Sexual Behaviour 1986 15(2): 97-119.

ICDDR,B. Male reproductive and sexual health in Bangladesh, Second Consultation Meeting, Rajendrapur, Dhaka, 22nd 25th August 2003.

[Jenkins, C.] Men who have sex with men (MSM) and HIV/AIDS. In Report on the Sero-surveillance and Behavioural Surveillance on STDs and AIDS in Bangladesh 1998-1999. Dhaka: Government of Bangladesh/UNAIDS, June 2000.

National AIDS/STD Programme. Directorate General of Health Services, Ministry of Health and Family Welfare, Government of the People’s Republic of Bangladesh. HIV in Bangladesh: Is time running out? Background document for the dissemination of the Fourth Round (2002) of the National HIV and Behavioral Surveillance. Dhaka, June 2003.

The World Bank Group. Issue Brief: HIV/AIDS. South Asia Region (SAR). Bangladesh. http:siteresources.worldbank.org/BANGLADESHTN/Resources/HIVAIDSBrief.pdf., 2003.

ACKNOWLEDGMENTS

The study was made possible through support provided to the CATALYST Consortium by the Asia and Near East Bureau. CATALYST staff time was funded by the ANE Bureau as well as the Office of Population and Reproductive Health, Bureau for Global Programs, U.S. Agency for International Development (USAID) under the terms of Cooperative Agreement No. HRN-A-00-00-00003-00 awarded to the CATALYST Consortium. The Consortium is a partnership between Pathfinder International and its partners, the Academy for Educational Development, the Centre for Development and Population Activities, Meridian Group International, Inc., and PROFAMILIA/Colombia. The opinions expressed are those of the authors and do not reflect the views of the staff of the U.S. Agency for International Development.

This study could not have been completed without the active support and participation of the following: Bandhu Social Welfare Society; the CATALYST Consortium; Family Health International, Bangladesh; ICDDR,B: The Center for Health and Population Research; and the USAID Mission/Bangladesh.

A great deal of thanks must be extended to: Shale Ahmed, Executive Director, who despite his enormous responsibilities in the overall management of BSWS, ensured that ongoing assistance and quality time was spent on this study; and Zakir Ahmed, Study Manager, who worked tirelessly under difficult social and political circumstances to manage the data collection and handled personal issues and concerns of the research team members, as well as many of the respondents.

All of the Study Team members achieved all the objectives in collecting the data, managing a difficult and sensitive process. They also dealt with a range of methodological issues, such as the need for increased interview time and longer focus group discussions. They showed remarkable patience, tolerance, and acceptance. The team members included: Rafiqul Islam Royal; Khondokar Parvez; Mamunur Rashid; Ms. Ranju Malakaar; Ashok Das; and Azad Uzzaman.

Our gratitude is also expressed to Zynia L. Rionda, Senior Advisor for Programs at the CATALYST Consortium for her patience, forbearance, and steadfast support; to Paula E. Hollerbach, Evaluation Advisor at the CATALYST Consortium, for her patience and willingness to learn and for her constant encouragement and support; and to Pam Baatsen of Family Health International in Bangladesh, and Matt Friedman of the USAID Mission in Bangladesh for their constant support and encouragement.

Finally, our profound appreciation to Kai Spratt, former HIV/AIDS Senior Technical Advisor of the Asia/Near East (ANE) Bureau of the U.S. Agency for International Development, for her initial interest and strong support in undertaking formative research on adolescence, and for her invaluable inputs in formulating its conceptual framework; to Andrew Clements, Senior Technical Advisor for Infectious Diseases, for reviewing the proposal and providing technical guidance on how the formative research could contribute to the ANE Bureau's HIV regional strategy; and to Billy Pick, HIV Technical Advisor, for his steadfast support to the CATALYST Consortium in the completion of the study report.

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