Men’s Condom Use or Non-Use and Health Risk: A Comparative Study on Premarital, Marital and Extramarital Men at Rajshahi City, Bangladesh

Md. Emaj Uddin^*, Zannatul Ferdous

Department of Social Work, University of Rajshahi, Rajshahi, Bangladesh

Abstract

This study explores and compares relationship men’s condom use or non-use and health risks in heterosexual intercourse in urban Bangladesh. For this 80 men (20 for single, 35 for marital and 25 for extramarital sexual intercourse) were purposefully selected from Rajshahi city, Bangladesh and intensively studied, using semi-structural questionnaire, in-depth interview method and case study technique. The study found that extramarital men were more likely to engage in commercial sex without condom than marital and premarital men. The findings also suggested that extramarital men who would not use condom were more likely to suffer from sexually transmitted infections or diseases (e.g., Chlamydia, Gonorrhea and Syphilis) than the marital men and premarital love-makers in the sexual intercourse. The study argue that extramarital men characterized by casual or commercial sex, illiteracy and lack of cognitive consciousness and more negative attitudes toward condom use were more likely affected by sexually transmitted infections or diseases than the marital and extramarital men with monogamous partner, more or less condom use, consciousness and positive attitude toward condom use. These findings may have implications in health policy and services to improve men’s sexual health in urban Bangladesh.

Keywords

Men’s Condom Use or Non-Use, Heterosexual Intercourse, Sexual Health Risk, Bangladesh

Received: June 29, 2015
Accepted: July 27, 2015
Published online: August 6, 2015

@ 2015 The Authors. Published by American Institute of Science. This Open Access article is under the CC BY-NC license. http://creativecommons.org/licenses/by-nc/4.0/

1. Introduction

Safer sex and consistent condom use during heterosexual intercourse that preserve reproductive and sexual health for both women and men is a challenging issue across societies, including Bangladesh (Ministry of Health & Family Welfare, 2005). Previous scientific literature has shown that men’s condom use during heterosexual intercourse is 70%-95% effective to prevent unwanted pregnancy and sexual health risks, including STIs, STDs, HIV/AIDS^7,24,38,58. Despite this knowledge and wide experience, recent empirical studies have shown that unwanted pregnancy, sexual health risks and its related health cost are increasing in association with the high rates (70% to 90%) of non-condom-use in marital and non-marital heterosexual relations across the societies, including Bangladesh^{11,13,15,17,40,46,47}.

Over past several decades previous quantitative and cross-sectional researches in Bangladesh have paid much attention on sociodemographic distribution of low prevalence rates (4% -8%) of men’s condom use in marital or non-marital heterosexual relations^34,35,44,57. The findings of the previous studies reveal that the low prevalence rates of men’s condom use during the heterosexual intercourses are linked to socio-demographic characteristics, including age, sex, social class, ethnicity, residence, religion and region. Bangladesh demographic and health survey (2004) has found that low condom use rate of ever married women (5.9 %) and men (4.2%) aged 15-49 years is associated with greater reproductive health risks (unwanted pregnancy) among adolescent girls, independent of socio-demographic characteristics¹⁹. Several studies on premarital^20,27 and extramarital sexual activities^6,33 have also shown that relations of inconsistent condom use or even non-condom use to higher sexual health risks (e.g., STIs, STDs) in lower socioeconomic groups (e.g., rickshaw puller, truck driver, launch workers, dock workers, out-migrants) than the men with higher socioeconomic status (e.g., student, Banker, and Businessman) in urban areas. Other studies have found that sex with only a marital partner (between monogamous husband and wife) or premarital love-partner  is safer than sex with casual or multiple commercial partners who may bear STIs, STDs and even HIV/AIDS^22,32. In this sense frequent extramarital sex (with commercial sex workers) is riskier than the marital sex and premarital sex (only between two intimate love-makers or dating partners). The findings of the studies have shown that the men who engage in frequent risky sexual intercourse without condom or inconsistent condom use have greater reproductive health risks among married or unmarried women (e.g., unwanted pregnancy and its negative health consequences) and sexual health risks for both men and women (e.g., STIs, STDs, HIV/AIDS) than the men who engage in sex with consistent condom use.

Previous quantitative and cross-sectional studies reviewed have contributed to the relationships of socio-demographic status with condom use or non-use in either marital or non-marital heterosexual sexual intercourse, but a few of the studies have critically addressed and compared men’s condom use or non-use and its related sexual health risks across the premarital, marital, and extramarital men in urban country^11,23. To fill in the knowledge gap this study has conducted to explore and compare men’s condom use or non-use and sexual health risks in premarital, marital, and extramarital sexual intercourse in Rajshahi city of Bangladesh, using qualitative comparative case study approach and in-depth interview. The findings of the study may have practical implications to design new health policy and practices to increase men’s condom use in premarital, marital and extramarital heterosexual intercourse with a view to protect men’s health from sexually transmitted health risks in Bangladesh.

2. Theoretical Framework

According to hedonistic approach or pleasure principles men want to avoid pains and get pleasures from heterosexual intercourse. Exchange theory also suggests that men want to get maximum pleasure with minimum costs²⁵. Based on the broader theoretical frameworks there are several alternative reasons or arguments of men’s condom use or non-use and sexual health risks in heterosexual intercourse. Khan Hudson-Rodd, Saggers, Bhuiyan & Bhuiya argue that bad smell, problems of storage, disposal/purchase, size of condom, especially reduced pleasure are the sole reasons for refusal to use condom or discontinue its use in heterosexual intercourse. They indicate that non-use of condoms for understanding of their bodily (genital) pleasure of sex acts is closely associated with sexual health risks^23,24.

The underlying assumptions of mass media and masculinity theory also suggests that men learn through pornographic films and long duration of masculine socialization that prolong intercourse and its outcome (ejaculation) without using condoms is real men’s sexual skills. The prolonged intercourse and late ejaculation increase men’s bodily images, sexual satisfaction and builds happily marital and family life. Based on the assumption several studies have found that men do not use condom or discontinue it, because using condom and its size during heterosexual intercourse impedes real feelings or pleasures in sex act and it also affects early ejaculation^23,24. They also have found that non-use of condom to get sexual pleasure is linked to health risks.

Social construction theory assumes that gender sexuality, condom use or non-use and its health risks depend on gender power relation, age, socio-economic status and ethnicity^5,10,12. The unequal power relation that favors a man than a woman in heterosexual interaction men’s sexual pleasure supersedes women’s, and men than women have greater control over when, where and how sex takes place for sensational pleasure without using condom. This imbalanced gender power relation expands more men’s sexual freedom and pleasure than women’s without using condom, thereby increasing genders’ reproductive, sexual and health risks/vulnerabilities to the epidemic^14,15,22-24.

The principle of cognitive model asserts that men’s (also women’s) decisions related to condom use or non-use and health risks in sexual activities fully depend on their cognitive factors (e.g., perception, memory, knowledge, strategies, inferences and experience acquired from their cultural belief and social relations. Yoskowitz, Gutnik, O’Sullivan, Kaufman & Patel (2005) assume that men’s decision regarding condom use or non-use depends on their beliefs and perceptions and in turn shapes their beliefs and perceptions. They argue that when individuals think their partners are safe, they do not use condom, but when they perceive some risks, because their partners are promiscuous they use condom^15,37,38. Based on the theoretical reasons some sociodemographic studies have found that men with low socio-economic status, cognition, consciousness and experiences compared to men with medium/high socio-economic status, cognition, consciousness and knowledge are the most likely to engage in unprotected sex have greater sexual health risks in their life^1-13.  Following these reasons behind theories and its related studies reviewed, especially pleasure principles and cognitive theory, the first assumption of this study is that extramarital and marital men with low socio-economic status, cognition, consciousness and experiences compared to premarital men with medium/high socio-economic status, cognition, consciousness and knowledge are the most likely to engage in sexual intercourse (extramarital men’s sex with commercial women and marital men with their wives) without condom use to have sexual pleasure. To do so, extramarital men (whose partners are commercial sex workers) compared to marital and premarital men (whose partners are monogamous) are at greater sexual health risks in urban Bangladesh^{6,11,15,17,20}.

Table 1. Sample Characteristics of Premarital, Marital and Extramarital Men, Rajshahi City, Bangladesh, 2009.

Source: Fieldwork, 2009

3. Data and Method

This study used qualitative comparative case study method (from selection of study setting, sample, method of data collection to data analysis) to explore and compare sexual health risks associated with men’s condom use or non-use in premarital, marital, and extramarital sexual intercourse in Rajshahi Metropolitan city, Bangladesh^48-50,54. Rajshahi Metropolitan city with more than 5 million people is one of the largest, modernized, mobile, educational cities (e.g., Dhaka, Chittagang, Narayangang, Shylhet, Khulna) in Bangladesh wherein premarital, marital, and extramarital heterosexual activities without condom use and its related health risks are increasing day-by-day due to expand urbanization and its related opportunities. In spite of it there is no single study on the sensitive issue to explore and compare men’s condom use or non-use in premarital, marital, and extramarital sexual intercourse and its related health risks in the city.

Case Selection

This study used purposive sampling strategy to select necessary samples, because the universe of the sensitive issue studied was not well-documented. Based on snowball process 70 premarital love-makers or dating partners, 50 marital couples, and 45 extramarital men who had sexual intercourse with their respective female partners were identified and then 20 men for premarital, 35 men for marital and 25 men for extramarital sexual activities were purposively selected, because they were sincerely agreed and consent to participate in the study process. The selected premarital men with ages 20-25 years, unmarried and having had sexual intercourse with their dating female partners were the students (came from rural villages to study at college and university level, Rajshahi city. The marital men aged 20-30 years who were the permanent residents at the city, rickshaw puller and recently married but had no issue. Most of the marital and extramarital men were illiterate. The extramarital men aged 25-40 years who were also married, illiterate and rickshaw puller come from different villages to this city aimed at earning and had had sex with the female sex workers in absence of their wives. For in-depth analysis of men’s condom use or non-use during heterosexual intercourse that might affect their sexual health risks some men (n= (2x2)4 for premarital, n= (2x2)4 for marital and n= (2x2)4 for extramarital) were selected.

Measures

Renowned social scientist McAnulty & Burnette and others have defined the term "sexual intercourse" as penile-vaginal coitus between a man and a woman to have sexual pleasure, to make love with each other, and to have a child (p.8)²⁹. Premarital sexual intercourse refers to the penile-vaginal coitus between a young male and a young female (also adolescents) who are unmarried and recognized each other as lovers or dating partners. When penile-vaginal coitus occurred between husband and wife is called marital sexual intercourse. When penile-vaginal coitus occurred between a married man and a woman (also a commercial sex female worker) and the vice versa is called extramarital sexual intercourse. Men's condom use or non-use during the heterosexual premarital, marital and extramarital intercourse refers to the presence or absence of reversible means or devices occurred in biological, psychological and broader socio-cultural context.

In order to explore and compare men’s condom use or non-use in premarital, marital and extramarital sexuality and sexual health risks in Rajshahi city of Bangladesh this study used several key concepts: age, education, occupation, duration of relation, sexual frequency and men’s condom use or non-use in sexual intercourse. Men’s sexual behavior pattern was classified into three groups and measured as: 1= Premarital sexuality, 2= marital sexuality and 3= extramarital sexuality. Duration of relation for sexual intercourse and its pleasure was numerically measured and accounted for as years of relations between male and female partners in premarital, marital and extramarital sexuality studied. Frequency of sexual intercourse was numerically measured and accounted for as numbers of intercourse in last month. Condom use or un-use was categorically measured and accounted for as 1= regularly, 2= sometimes and 2= none. Sexual health risks refer to the germs or poisons that transmit from one person to another without using condom. These germs or poisons may affect both men and women reproductive and sexual health³³.

Instrument and Procedure

Based on research purpose this study was conducted at Rajshahi metropolitan city from July to December in 2009. In so doing, we used semi-structural questionnaire with in-depth interview technique to study men’s sexual health risks associated with condom use or non-use in the sexual behavior patterns in the city. Participation of the respondents in the study was voluntary with no direct benefits. The selected cases were guaranteed confidentiality and anonymity. Informed consent also was obtained from the selected cases before data collection, with confidentiality and anonymous assurance^48,55. We collected data on the research purpose in two phases. In the first phase of data collection from July to August 2009 we built up rapport with our respondents selected. In rapport-building interview with semi-structural (open-ended) questionnaire was used to collect background information, such as age, residence, education, occupation, identity of marital, premarital and extramarital partners, duration of sexual relation, sexual frequency and condom use or non-use during sexual intercourse in the Rajshahi city⁴⁸. In the second phase of data collection in-depth interview was conducted with the selected cases to collect data on the reasons of condom use or non-use and its related sexual health effects^6,22-24. In so doing we intimately discussed on the crucial research themes with our respondents and written technique was used to collect and record data given by our respondents. Each in-depth interview was conducted in personal and private setting lasted for 1 and half hours. After completion interview we gave special thanks to every male respondent.

Ethical Consideration

Exploring reasons for men’s condom use or non-use in their heterosexual intercourse are socio-culturally sensitive issues in conservative cultures, like Bangladesh. In order to select the respondents (e.g. premarital, marital and extramarital men and conduct in-depth interview with semi-structural questionnaire from them this study maintained some ethical considerations, including confidentiality, informed consent, privacy, mutual benefit and reciprocity. First of all informed consent to conduct the study was collected from the respondents the respondents were assured that personal identity and relevant data collected with written questionnaire and in-depth interview and case study analysis from them would be safe, private and confidential⁵⁵.

Analysis of Data

We analyzed the data on the research issue based on qualitative approach. In so doing the information our respondents provided were post-coded. Data by post-coded was presented in tabular form (see table 1-3). In addition, we also analyzed qualitative data on the sexual frequency and men’s condom use in every sexual intercourse with case illustration. This case illustration provided real pictures of the research themes studied. The findings and publication of the research would never be harmful for them.

4. Result

Type of Partner and Sexual Frequency

Sex is one of the basic human needs that eligible people meet in hetero-sexual relations: premarital, marital and extramarital relationships. The first objective of the research was to explore and compare duration of relationship and sexual frequency among the premarital, marital and extramarital men in Rajshahi city of Bangladesh. Table 1 shows that average duration of relationships of the selected men were 5.5 years for premarital (love-mates), 2.14 years for marital and 1.48 years for extramarital men interviewed with semi structural questionnaire. In such duration of relationship average sexual frequency was higher among the marital men than the premarital or extramarital ones with their female partners.

Regarding this our respondents said:

One marital man age 25 years says I believe in marital sex. I frequently consume sex at night.

One premarital man (student) age 20 years says I believe in love relation, I sometimes enjoy…….

Extramarital respondents inform that we are married, but our wives are out of this town. As we are habituated sex, we cannot sex with our wives. When we feel sex, we go to the prostitutes and I sometimes consume sex in exchange of money.

Condom Use or Non-Use

Another objective of the study was to explore differences in men’s condom use or non-use in sexual behavior patterns in the study area of Bangladesh. Data in the table reveal that regular condom use in relation to sexual frequency was higher among premarital men (60%) compared to marital (25.75%) and extramarital men (20%). But sometimes condom users were higher among marital men (45.71%) than the extramarital and premarital men. In addition, non-condom-users were higher among marital men (57.14%) than the premarital (10%) and extramarital men (52%). Regarding this our respondents said:

Marital men sometimes use condom at hand, we have no fear to conception and any transmitted diseases, because our wives are more or less free from any transmitted diseases.

Premarital men say that although our female partners are beautiful, healthy and free from any transmitted diseases, we become fear if our female partners become pregnant. To avoid pregnancy we always use condom.

Premarital men say……..premarital sex is not permitted in our Muslim culture, our female partner cannot use any condom or birth control methods, such as pill. Other inform…..sex is emotional acts emotion never obey….

Extramarital men say….. we are not habituated to use condom in intercourse with our wives, so we sometimes use condom. Some extramarital men say…. We never feel sexual pleasure using condom…. Other informs I always cannot bear condom when I go to the prostitute.

Condom Use/Non-use and Sexual Health Risks

Although condom is a popular method and is easy to use in sexual intercourse, many of the men did not use condom in intercourse with their partners. As a result they were affected by STDS and HIV positive. Present study using in-depth interview found that the premarital or extramarital partners who did not use condom in sexual intercourse easily affected by sexual diseases. For example, extramarital men informed us we would almost suffer from some health problems, such as Chlamydia, Gonorrhea and Syphilis. An extramarital man informed us….

I am suffering from Gonorrhea detected by doctors for six months, because I would never use condom in commercial sex act to have sexual pleasure.

For the marital and premarital men who sometimes or never used condom, many times of their female partners became pregnant. In order to solve this problem they made MR to go to the doctors in the city. As a result their female partners would suffer from reproductive health problems (Caldwell & Pieris 1999; ICDDR, B 2008; Melhado 2007). A premarital man said…..

In dating I would always excite…. Then I would engage in sex…..without condom and my female partner became pregnant.

5. Discussion

Based on evidence including our findings we may conclude that premarital, marital and extramarital sexuality more or less exists in every society or culture. In order to fulfil sexual need eligible people in Bangladesh engage in intercourse and use condom all these patterns of sexuality. Findings of this study suggested that premarital men compared to marital and extramarital ones would almost regularly use condom in intercourse with their female partners, because they were more conscious to pregnancy and STDs. As a result, extramarital men would suffer from STDs than the other men in the Rajshahi city of Bangladesh.

Based on normative and ethical theory some researchers argued that sexual frequency in the sexuality patterns depends on the normative development of sexual relationship and ethical and legal legitimacy in sexuality patterns. As premarital and extramarital sexuality are not ethically and legally recognized in this culture, especially among the Muslims, premarital and extramarital men cannot involve in frequent sexual intercourse with their female partners like marital men’s. Therefore, their sexual frequency was lower than that the marital men^1-21. Based on theory of motive and cognition researchers explained that condom use or non-use in sexuality patterns fully depends on men’s purpose of sexuality, motivation to it and consciousness about its bad or negative effects.

Although purpose of all men in sexual involvement were the same, to meet sexual need and satisfaction, motive of condom use of the men were completely different^22-37. Purpose of condom use of the marital men was to prevent immediate or unwanted birth, but purpose of the premarital and extramarital men’s condom use was to protect illegitimate birth and sexually transmitted diseases. Another argument of the cognition theory was premarital sexual men were socio-culturally and cognitively conscious about condom non-use, such as illegitimate birth, most of them used condom regularly or irregularly than the marital or extramarital men. These findings of the study may be implied in further research investigation, orientation to health policy and services to improve men’s sexual health^37-47,52,59.

Acknowledgement

Authors of this article acknowledge the respondents who actively participated in the study and sincerely gave data used about the men’s condom use or non-use in heterosexual behavior in urban Bangladesh.

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