Arunrat Tangmunkongvorakul

1. Sexual Health in Transition:Adolescent Lifestyles and Sexual Relationships in Contemporary Chiang Mai, Thailand Arunrat Tangmunkongvorakul

2. Background • In the past, sexuality was not a subject to be discussed in public and too little factual information was provided • Data on sexual behaviour became widespread in 1990s, mostly driven by the HIV epidemic and in response to public health demands

3. Changing Sexual Conduct among Young Men Worrying about AIDS and commercial sex, Thai men have turned to other ways of fulfilling their sexual desires • Those in urban middle-class settings pay for sex with non-brothel sex workers • Others turn to big-city singles bars for casual sex with pick-up partners • Growing number of young men who have sex with their girlfriends in the context of committed romantic relationships

4. Modernization Rapid development of information technology Ways of living have changed Young Thai people are healthier, more urbanised and better educated The downside is the more widespread adoption of unhealthy lifestyles - Fast food - Alcohol, tobacco and narcotic use - Night-time recreational activities - Unsafe premarital sexual behaviours

5. Northern Thailand Chiang Mai • Geographically and linguistically different from other regions • Many speak some variation of northern Thai dialects • Centred on Chiang Mai City • A key node for provincial development • A major site of in-migration for young people moving for education and work

6. Justification • Health lifestyle research has not yet emerged in Thailand • Not much research on the characteristics and diversity of lifestyles and sexual activities of young people • Few studies explain how modern lifestyles and relationships are interpreted by individual adolescents of different socio-economic positions

7. Aim of This Study • To gain a comprehensive understanding of contemporary young people’s lifestyles and relationships, and their sexual and reproductive health in Chiang Mai City • To provide constructive information to help plan and implement health policy, and to improve sexual and reproductive health counselling, programs and services for young people in Northern Thailand

8. Specific Objectives • To describe and compare the lifestyles and intimate relationships of adolescents in different social groups • To explore sexual diversity among adolescents in urban Chiang Mai today • To describe sexual experience and investigate the social, economic and cultural factors associated with sexual practices among adolescents • To explain the sexual and reproductive health consequences for sexually active adolescents, and the use and perceptions of sexual and reproductive health services among adolescents

9. Study Population and Recruitment • UNFPA (1998) defines the age group of adolescence to be 10-19 years, but the age group 17-20 is envisaged to be able to look back to their earlier teenage years • This study therefore focuses only on adolescents • Aged 17-20 • Unmarried (culturally or legally) • Students and non-students • Both sexually experienced and not experienced • Spotlight on urban areas

10. Study Population and Recruitment • Sample size – total 1,749 • 909 males and 840 females • In-school: 3 vocational schools, 2 general schools, 1 university • Out-of-school: non-formal education centres (6 sites), game shops, shopping malls, public gardens, places to meet young people

11. Methods • Quantitative data • Questionnaire survey (Total 1,749) • Qualitative data • In-depth Interviews; Total 30 (M 16, F 14) • Focus group discussions (16 groups) • Supplementary data (observations, documentary research and key informant interviews)

12. Young Research Team May Kan Gift Beer

13. Research team also worked with NGO staff members who work with young people in the workplace, neighborhood and community, and the streets or public places, to contact prospective respondents.

14. Findings • Lifestyles and intimate relationships of adolescents in different social groups • Sexual experience • Sexual and reproductive health consequences for sexually active adolescents • A need for special services for young people

15. Characteristics • Among 1,749 respondents: • 48.0 % females • Ages from 17-20 years, mean 19.3; 72.8 % aged 18-19 • 91.3 % practiced Buddhism • 88.6 % were cared for by parents when they were young • 86.6 % received regular allowance from parents/guardian • 76.7 % were currently attending formal school • Less than half respondents currently live with their parent(s) (47.8 %), spent most of their life in Chiang Mai city when young (37.8 %), and worked to earn money (26.8 %).

16. Lifestyle and Intimate Relationship • All respondents (1,749) • 79.9 % spent time regularly hanging out with friends (mean 27.9 hours per week) • 62.4 % talked often on the phone (mean 11.4 hours per week) • 84.0 % owned a mobile phone themselves • 76.4 % had already watched an X-rated movie • 67.9 % had ever dated someone • 57.8 % reported currently having a girlfriend/boyfriend • Among those who had a current loved one • 63.3 % had sex with him/her • 18.8 % of these used condoms consistently • 24.9 % currently lived with their girlfriend/boyfriend

17. Comparing between groups • Compare the family socio-economic statuses, lifestyles and intimate relationships of male and female respondents who were from different social groups • Educational background was used to stratify the respondents into three groups: • Out-of-school adolescents (group O) • Vocational school students (group V) • General school and university students(group G)

18. What was your father's highest completed level of education? Vocational General Out of School

19. How skilled is your father's occupation? Vocational General Out of School

20. What is your parents' monthly income (father and mother added together)? Vocational General Out of School

21. What is your parents' marital status? Vocational General Out of School

22. Car Vocational General Out of School

23. Air Conditioning Vocational General Out of School

24. Activities in daily life

25. Alcohol and cigarette use

26. Illegal drug use

27. Opinions of love and intimate relationships(1) • Respondents from different educational groups had significantly different opinions • Groups O and V • It was all right for boys and girls to have affectionate contact (kissing and hugging), sexual contact and sexual intercourse before marriage • Sometimes a boy wants a girl to have sex if he loves her • Nowadays older people accept sexual relationships among adolescents • Their parents would not blame them if they had sex • Most of their friends already had had sexual intercourse • One - night stands were OK

28. Opinions of love and intimate relationships(2) • Group G • Disagree that a boy and girl should have sex before becoming engaged to see whether they were suited to each other • Would never contemplate their partner or themselves having an abortion • Agreed that both boys and girls should remain virgins until they marry • Did not agree that it was mainly the woman’s responsibility to ensure that contraception was used regularly

29. Sexual relationships

30. Sexual experience

31. Sexual experience

32. Respondents who reported never having had sexual contact or intercourse • They cared about their parents’ feelings • Females from group G had very strong opinions on this • Males from group V tended to state that they had not had sex because they had not had the opportunity • Females tended to state that they would wait until marriage • Males planned to wait until they found someone they loved or until an opportunity came along

33. Respondents who reported never having had sexual contact or intercourse • Four out of ten had ever dated someone • Those who had had the experience of dating • More than 80 percent had ever held hands • About half had kissed on the cheek • Around one-quarter had ever kissed on the lips • One-tenth had engaged in petting • One-third currently had a boyfriend/girlfriend • Those from group V were most likely to report this

34. Respondents who reported having had sexual intercourse • Mean numbers of lifetime sexual partners • Males: 6.6 (median 4.0) • Females: 3.5 (median 2.0) • Friends were persons who knew of their sexual intercourse status • Parents, siblings and teachers were much less likely to know of this status • Those from group G were least likely to state that other people knew of their sexual intercourse status

35. First Sex • Mean age at sexual debut • males 16.05 • females 16.53 • Venue • Males: mostly happened in their own room/house • Females: at a partner’s place • Sexual partner • Males: more had first sex with an acquaintance, other friend or stranger • Females: more as a boyfriend/girlfriend • Only 1 % of males reported that their first sexual partner was a sex worker

36. First Sex • Protection • Males: 52.0 % used a condom, 25.4 % used withdrawal and 19.4 % used no method of contraception • Females: withdrawal technique was the most common method (39.8 %), while 31.5 % used a condom 20.4 % no method • Females from group V more often used withdrawal, while group G tended to use condoms and group O were the most likely to have used no method

37. Most recent sex • 56.9 % of the sexually experienced had had sex in the last week (male 54.4 %, female 61.6 %) • The last partner was usually a boyfriend/girlfriend, although more males had had sex with an acquaintance, other friend or stranger • Only 0.9 % of males reported a sex worker as their last sexual partner

38. Most recent sex • Protection • More males (47.3 %) than females (28.0 %) reported on having used condoms • Females reported more on using withdrawal (F 32.6 %, M 27.0 % ) and oral pills (F 13.1 %, M 5.5 % ) • Males and females from group V tended to use withdrawal technique • Those from group G tended to use condoms • Those from group O were the most likely not to have used any contraceptive method

39. Casual sex • 43.0 % sexually experienced males had had casual sex, while it was 16.9 % among females • Half of out-of-school males and nearly one-third of out-of-school females having had this experience. • 47.6 % of those with such experience had had casual sex 2-5 times • Protection • Males: 57.0 % reported using condoms consistently • Females: 37.5 % reported this

40. Paid Sex • Less than one-tenth had ever accepted money and/or other resources to allow someone to have sex with them • Only 5 % had ever paid for sex • Consistent condom use in paid sex was reported at 69.2 % among males, but only 37.5 % among females • There was no significant difference across the three educational groups

41. Coercive Sex • Males: 8.8 % • Females: 26.4 % • Sex partners involved had usually been loved ones • Coercion had largely occurred at first sex • Coerced females (41.3 %) were less likely than coerced males (61.2 %) to report the use of condoms in these encounters • Sexual coercion: ranging from non-physical forms such as verbal sexual abuse and forced viewing of pornography through unwanted contact in the form of touching or fondling to forced penetrative first sex

42. Sexual health consequences • 38.5 % had itching around the opening of the penis/vagina • 36.8 % had painful or burning sensation when urinating • 10.5 % had ulcer or sore in their genital area • 8.7 % reported abnormal genital discharge • Among females only, 14.2 % had ever had vaginitis/cervicitis and 5.3 % had had pelvic inflammatory disease • Less than 5 % reported having had gonorrhoea • Only 1-2 % reported having had syphilis or genital herpes • 3.6 % had had Chlamydia: males (4.6 %) reported more often than females(1.8 %) • Nobody reported having been HIV infected

43. Approach to treatment last time • More than one-third reported that they did nothing • A quarter visited a health professional • Males more likely to have visited public hospitals/clinics • Females tending to have used private facilities. • Around 15 % went to a pharmacy asking for advice and to buy drugs, • 6 % bought drugs from convenient stores • The rest (20 %) received drugs from friends or reacted in a combination of the ways just discussed

44. Birth control • Withdrawal was the single most popular method • Most sexually experienced respondents (86.4 %) having ever used it • Half of males and females reporting using it most to all of the time. • Condoms were the second most popular method • Males (47.3 %) more likely than females (32.4 %) to report using this method most of the time • Females much more likely to have never used it (F 24.5 %, M 11.7 %) • Males and females from group G were more likely to report that they used condoms most to all of the time.

45. Birth control • Oral pills: more widespread among females (32 % of them using this method all or most of the time while only 20.6 % of males reported that their partners were regular users of the method ) • Periodic abstinence: Nearly 60 % having ever used it and 30 % reporting having used it most or all of the time. • Morning after pill: around 30 % had ever used it (only occasionally) • Less than 10 % had ever used injection, IUDs, Norplant and traditional herbal remedies.

46. Pregnancy • Females (30.5 %) more often responded affirmatively than did males (17.5 %) • Among females: • 40.2 % of those from group O • 32.0 % among group V • 14.7 % among group G • Among males: • 25.4 % of those from group O • 14.8 % among group V • 8.8 % from group G • Number of pregnancies • Males: mean of 1.48 (median of 1.0) • Females: mean of 1.45 (median of 1.0) • Maximums for both sexes: 4 pregnancies

47. Outcomes of Pregnancies • 65.2 % of respondents reported them ending in abortion • No difference between males and females in the patterns of pregnancy outcomes reported • Pregnant vocational school females tended to report that they had had an abortion (85 %). • 26.5 % of males from the out-of-school group who had been involved in a pregnancy reported that their partner had had a delivery • Among ever pregnant female respondents, 52.8 % of those from the out-of-school group reported that they had carried their pregnancies to term

48. Abortion • Median = 1.00 (male mean = 1.33; female mean = 1.43 abortions) • Maximum: Males = 3, and females = 4 • Ways in which the most recent abortion had been sought: • Almost half had resorted to self-induced abortions (using illegal abortificients) • One-third went to a private clinic or hospital • Less than 10 % went to public health organizations • Outcome of the most recent abortion: • 62 % had involved no complications • 11.4 % had involved minor complications • 7.2 % had severe complications requiring treatment at a clinic or hospital (M 5.7 %, F 9.1 %) No differences between sexes or between educational groups

49. Mental health and wellbeing • Male: • sexually inexperienced males were more positive than their sexually experienced counterparts in feeling that they were as good as other people. • Females: • Sexually inexperienced ones tended to spend much more time • Enjoyed life; Were energetic; Were hopeful about the future • Felt that they were as good as other people • Felt that people liked them. • Sexually experienced ones tended to have spent more time recently with negative feelings • Lonely; Bored with their lives; Experienced restless sleep; • Had crying spells • Thought their lives had been failures

50. Self-harm • Males (14.3 %) • No significant difference emerged between those who were sexually experienced and inexperienced • Females (15.6 %) • Those who had had sexual intercourse were more likely to have ever tried to harm themselves (26.1 % vs. 10 % of those with sexually inexperienced), and such attempts had often required treatment by a doctor (12.2 % vs. 0 %)