Gender differences in exposure to SRH information and risky sexual debut among poor Myanmar youths

Globally, the proportion of youths has been steadily increasing, especially in developing countries across Asia. Among all youths, 60% is currently living in Asia [1]. The period of adolescence or young adulthood is important since it is a transitional period in which youths start to become curious about their sexuality and experiment with new sexual activities. It is also an opportunistic period for them in which they must learn to adapt and make important decisions for embracing their future. Failure to provide adequate sexual and reproductive health (SRH) information to youths combined with their lack of exposure to this information during this transitional period may lead to major public health implications such as STI/HIV infections, unwanted pregnancies and unsafe abortions as well as risky sexual debut [2, 3].

First sexual intercourse, or sexual debut, is a normal part of human development when youths are exposed to sex for the first time in their lives. Sexual debut is important because the earlier age at sexual debut, the more risky sexual behaviors become later in life [4]. According to United States’ Centers for Disease Control and Prevention, risky sexual behaviors include having sex at an early age (16 years or younger), having multiple sexual partners or non-regular partners, having sex while under the influence of alcohol or drugs, and unprotected sexual behaviors (not using any condoms or contraceptives). Nowadays, early and risky sexual debut among youths is increasing worldwide along with higher adverse RH consequences [5]. Adequate exposure to proper SRH information has been shown to have a protective effect on risky sexual behaviors and reduce negative RH outcomes [6, 7]. However, various socio-economic factors deter youths from receiving basic SRH information as well as achieving a safe and responsible sexual debut [3, 5, 8, 9].

Among social variations which influence youth’s RH behaviors, gender difference is an important issue to focus on nowadays. Evidence has shown that males take more sexual risks than females [5, 9, 10]. Younger age at first sex and premarital sex is more common among males [10, 11]. Females have more negative attitudes towards sex, such as shame and guilt, compared to males and are less likely to engage in premarital sex as well as sex with non-regular partners [9]. Females are socio-economically more vulnerable, especially in poor communities and are more likely to be coerced into sexual debut and early marriage than males [12, 13]. In addition, SRH for youths is a culturally sensitive issue in most Asian countries [14]. This issue is inadequately addressed in some countries leading them to have more adverse RH outcomes. A thorough identification of gender specific factors which influence exposure to SRH information and risky sexual debut among youths will help to establish culture and gender appropriate solutions in improving youth’s RH in most Asian countries.

Myanmar is one of the Asian countries in which youths constitute a significant proportion of the country’s population [15]. Early, premarital and risky sexual debut is not uncommon [16–18]; however issues on youth’s sexual behaviors have so far been poorly understood and scarcely addressed in the country due to cultural reasons. Determining the factors associated with exposure to SRH information and risky sexual debut among youths is an urgent issue for policy makers. This study thus aimed to identify gender differences in exposure to SRH information and risky sexual debut and their associated factors among poor Myanmar youths in suburban communities of Mandalay City.

The levels of exposure to SRH information and risky sexual debut among poor youths in suburban communities of Mandalay City, Myanmar were unfavorable. Gender differences were clearly seen for both exposure to SRH information and risky sexual debut. Specific influential factors affected RH behaviors differently between males and females. While parental guardianship and media exposure influenced exposure to SRH information among males, these factors were not significant among females. Education and willingness to have sex were influential for females’ exposure to risky sexual debut; however, only having a positive norm of premarital sex affected males’ exposure to risky sexual debut.

The level of exposure to SRH information (mainly on sexuality and STI/HIV) among males and females in our study was lower compared to that of Indian and African studies conducted among youths [20–22]. On the other hand, the level of early sexual debut among both males and females was alarmingly high in our study compared to a Chinese study in which sexual debut before age 18 among youths was rare [10]. The rate of premarital sex in our study was higher than that in studies conducted in Nigeria and Eastern Ethiopia; however the rate of condom non-use at sexual debut and having sex with a non-regular partner was similar to our study [11, 23]. The possible explanation for these differences can be due to the different study populations and settings. The participants in the other studies were mostly drawn from the general population [23] or university students [11] whereas our study was conducted among poor suburban youths who were socially and economically vulnerable.

Among known socio-economic variations affecting youth’s RH behaviors, gender played a significant role in many studies in different settings as well as in our study [5, 9, 10]. Our study found that females had obvious socio-economic vulnerabilities compared to males, e.g. having a lower income and education, being unemployed, and having a higher exposure to sex and marriage. It is notable that the rate of unwillingness at first sex or being forced into sex was extremely high among females in our study compared to a study conducted among out-of-school youths in China [24]. These findings confirmed the existence of gender inequality among youths in our study area.

Despite those limited socio-economic conditions, females had a higher exposure to SRH information, especially on STI/HIV compared to males. A similar finding was seen in a study conducted among African American adolescents, in which females had a higher knowledge of STI/HIV [25]. In that study, sexual experiences played a major role to get a higher knowledge of STI/HIV; however, youth’s preferred sources of information might be the main reason of this difference in our study. We found that females received SRH information mainly from health personnel but most males responded that they received SRH information from unreliable sources, such as friends or older youths in their community. This finding was also evident in a study among Indian male youths in which participants happened to receive SRH information from unreliable sources [26].

In addition to gender, we also found that age and schooling status influenced the exposure to SRH information among both males and females. Adolescents had lower exposure to SRH information compared to older youths probably because of their own embarrassment to access the available information or the cultural barrier which deters them to do so [27–29]. Out-of-school youths had a lower exposure to SRH information, a finding similar to a study conducted in China [24]. Even though the importance of schooling status for SRH education has been internationally recognized and addressed, this finding highlights the lack of solutions on providing SRH information to this vulnerable out-of-school group in recent SRH education programmes.

It is notable that exposure to mass media and parental guardianship also affected the exposure of SRH information only among males. A study conducted among young-unmarried men in India showed that these men also received SRH information mainly from the mass media [26]. In contrast, mass media was significantly associated with beliefs that increased the likelihood of sexual exposure among adolescents in the US [30], a finding which highlights the importance of mass media among male youths and its ambiguous effects on their RH behaviors. On the other hand, in our study having both parents as guardians was a positive influential factor on males’ exposure to SRH information. Thus, parental support or parental control was important not only for young people’s SRH behaviors, but also for their exposure to SRH information [24, 31].

Gender differences were also seen in risky sexual debut behaviors among the study participants. Females had a lower odds of having a risky sexual debut behaviors compared to males, a finding supported by many other Asian and African studies [5, 9–11]. This might probably be because males have a higher interest in sexual pleasure, freedom of motivations to have sex, and lesser feelings of guilt and shame after sex compared to females [9, 32]. In addition to gender, education, willingness to have sex at sexual debut and positive norms of premarital sex were important for youths’ exposure to risky sexual debut.

A higher education level was a protective factor of risky sexual debut among females, a finding which was supported by many other studies [33–35]. Education is an essential enabling factor which improves all aspects of women’s RH life. This finding could probably draw the policy makers’ attention to the importance of young girls’ school enrolment in these poor communities. The finding that females who had sex unwillingly or were forced into sex at their sexual debut were more likely to be exposed to risky sexual behaviors was also supported by a systematic review conducted in the US [36]. Women with violent or controlling male partners were at increased risk of HIV infection and risky sexual behaviors. The postulation was that abusive men were more likely to have HIV and impose risky sexual practices on their partners [37].

Males having a positive norm of premarital sex (males who replied that their friends had premarital sex, that it was very common and usual in their community and those who perceived that there was nothing wrong with premarital sex) were more likely to be exposed to risky sexual debut in our study. Sexual norms are important among youths. While positive norms of premarital sex increased the risk of risky sexual debut, virginity norms of males delayed sexual debut among rural Ethiopian youths [38]. This confirms the fact that complexity of social norms affects youth’s sexual behaviors differently through peers or society [39].

Some strengths and limitations of our study should be mentioned. One of the strengths of this study is that it elicited gender differences in exposure to SRH information and risky sexual debut among youths in hard-to-reach, poor, suburban communities of Myanmar. However, there were some limitations. First, the issue of risky sexual debut is culturally sensitive; therefore, some youths might have been reluctant to reveal their sexual behavior in detail. This may have caused an underreporting in the prevalence of this outcome. However, anonymity and confidentiality were emphasized and the interviewers were of the same gender as the youths they interviewed. Second, the youths in our study were located in poor communities, thus the generalizability of our findings may be limited. Third, even though considerable efforts were undertaken by the community leaders and municipal authorities to ensure a complete listing of youths in the study area, some youths may have not been included in the sampling frame.

Gender was significantly associated with exposure to SRH information and risky sexual debut among youths. These gender differences in sexual behaviors and risks highlight the need for gender specific solutions and approaches to achieve better SRH outcomes among youths. Policy makers as well as local RH care providers should be aware of those different influential factors between males and females. The reliability and sufficiency of current SRH information available in mass media should be assessed and enhanced accordingly. More dissemination of appropriate SRH information via youth-accessible mass media (e.g. television, radio) should be carried out, especially among males. Female empowerment should be emphasized (e.g. education, employment) in these poor communities while male norms on premarital sex should be corrected accordingly through intervention programs. RH risks among this vulnerable group need to be continuously monitored.