Undergradthesis MINE

Contents
Foreword ............................................................................................. vii
1. Talking Sex:
Anthropological Narratives in Sexuality Research
Michael L. Tan . ................................................................................3
2. Representations of Gender and Sexual Identity in Research

Suchada Thaweesit . ......................................................................19
3. Gender and Sexual Health of Adolescent Females

in Northern Thailand
Arunrat Tangmunkongvoraku
Pratima Bhuttarowas ....................................................................37
4. Sexual Behavior of Young Out-of-School Males

in an Indonesian Urban Slum
Laurike Moeliono ..........................................................................71
5. Sexual Behavior of Street Gangs in Davao City, Philippines

Marigrace B. Duropan
Grethyl Gumagay
Leah Mae Jabilles . .........................................................................97
6. Providing Contraceptive Services to Unmarried Youth

in Vientiane
V. Sychareun
T. Boupha, S. Kounnavong,
B. Thovisouk, K. Prabouasone
V. Hansana . ..................................................................................125
7. HIV/AIDS Telephone Counseling

in Shanghai and Guangxi, China
Yanning Gao .................................................................................155
8. Homosexuality and AIDS in Mainland China

Zhang Beichuan ...........................................................................201
Introduction
This publication on Researching Sexuality and Sexual Health

in Southeast Asia and China is a compilation of eight papers
selected from presentations given at the 6th Asia-Pacific Social
Sciences and Medicine Conference in Kunming, China, during
October 14-18, 2002.
The selected papers provide some indication of the state
of sexuality and sexual health research in the region. There
is an emphasis on knowledge and behavior and most of the
studies focus on youth or other so–called risk groups.
In “Talking Sex,” Michael Tan stresses the value of
anthropological narratives and original language with
verbatim quotes to “bring out people’s voices” in research.
Through qualitative research techniques and often loosely-
structured, spontaneous or casual encounters, narratives can
be generated to allow us insight into sexuality–what people
are thinking, how they plot risks and pleasures in their lives
and how they are processing the world around them.
In the second paper, “Representations of Gender and
Sexual Identity in Research,” Suchada Thaweesit, looks
through the theoretical lens to examine how a discourse
analytical framework can be used to interpret cases of
women negotiating pre-marital sex and negotiating the
sexual and asexual self. By applying the concept of “fluid
subjectivity,” the researcher may break down traditional
dichotomous constructions of women’s gender and sexual
Researching Sexuality and Sexual Health in Southeast Asia and China
identities, such as “good-bad,” “modern-conservative,” etc.

This study looks at the ways in which social values, norms
and ideologies regarding gender identities and sexuality
have been constructed. It finds discrepancy and sometimes
contradiction between sexual norms and actual behaviors,
indicating the political importance and the role of discourse
in domesticating, limiting, and controlling. The “essence of
verbal silences” is noted.
A ru n r a t Ta n g m u n k o n g v o r a k u l a n d P r a t i m a
Bhuttarowas’s paper on “Gender and Sexual Health of
Adolescent Females in Northern Thailand” considers the ways
in which gender double standards and power imbalances
confront sexually-active adolescents, acting as obstacles to
the attainment of sexual and reproductive health services in
Thailand. It sheds light on the experiences and perspectives of
both the youth themselves as well as service providers working
with unmarried youth. At the various levels of partner, family,
and provider, the study finds power imbalances in sexual
partnerships, lack of communication with parents on sexual
matters, and unfriendly care and judgmental attitudes on the
part of some providers. Again the extreme vulnerability of
sexually-active female is highlighted and interventions are
proposed.
Laurike Moeliono discusses the “Sexual Behavior of
Young Out-of-School Males in an Indonesian Urban Slum,”
taking the case of Duri Utara in Jakarta. Poorly educated
with few employment opportunities, young males (aged 15
to 24 years) turn to peer networks and tongkrongan (places
to hang out) for support, information and counseling.
These peer networks may not be entirely positive, with

reported risky sexual and related behaviors including drug
use. Providing evidence of the extreme vulnerability of
marginalized urban youth in Jakarta, Moeliono finds sexual
health needs are neglected. For many among these young
men, infection and pregnancy are not necessarily perceived
as negative outcomes of sexual relations, but rather as events
reinforcing masculinity and male prowess. Interventions such
as counseling opportunities, mentoring programs, education
(for both youth and parents), life and vocational skill-building,
employment opportunities, and other recreational activities
are recommended.
In a similar study considering the Philippines context,
Marigrace B. Duropan et al. explore the “Sexual Behavior of
Street Gangs in Davao City” and in particular the phenomenon
of buntog, where a female is the sex object for gang sex initiation.
The researchers discuss how young people (aged 12 to 19 years)
who join street gangs often come from the marginalized sector
of society and the ways socio-cultural environment influences
behavior and personalities. The research reveals that both male
and female street adolescents join gangs for companionship,
identity, emotional support, common interests, fun, casual
sex, curiosity, and protection in the street. Support services
are examined and recommendations are presented.
Continuing the investigation into how youth sexual
health needs are being met, the research team from Laos, V.
Sychareun et al. presents findings on “Providing Contraceptive
Services to Unmarried Youth in Vientiane.” By investigating
youth and provider experiences and attitudes, this paper
evaluates the effectiveness of health service providers in

the formal and informal sectors in providing contraceptive
counseling, condoms and other services. In the Lao context,
findings show that there is noticeable discomfort when
discussing contraception on the parts of both the service
providers and the young people. While apparently informal
sector providers are preferred for the convenience, relative
anonymity, and confidentiality they offer, many service
providers are unaware that unmarried youth remain
somewhat reluctant to access their services. Fear of breach
of confidentiality by service providers is a lingering doubt in
the minds of Lao youth.
Yanning Gao presents research on “HIV/AIDS
Telephone Counseling in Shanghai and Guangxi, China.”
Yanning’s conceptual framework identifies the characteristics
of callers and providers, the features of telephone counseling,
interactions between callers and providers, the contents and
functions of calls, as well as counseling techniques used by
providers. A psychological pattern of the HIV-hypochondriac
callers is investigated. As WHO sees the main functions
of HIV/AIDS counseling as prevention and support,
recommendations are made for the outreach program to
fulfill the multiple needs of callers including IDUs, CSWs,
and adolescents, a strengthening of the psychosocial support
functions of hotlines, and new training modules.
Zhang Beichuan’s study of “Homosexuality and AIDS
in Mainland China” investigates the economic and cultural
factors contributing towards the situation of homosexuals in
China today. Working with study groups from 1994 to 2001
and initiating a health education program called “Friends” in

1998, Zhang explores sexual behaviors and impacts on urban
homosexuals and their families. He suggests there is a clear
need for political support, resources, network support, and
public education, especially education of scholars in the field
with regard to human rights and individualism.
These studies are an important first step in
understanding the plural manifestations of sexuality and
sexual behaviors in Southeast Asia, and the sexual health needs
that are arising due to rapid social cultural changes. However,
there are still many gaps and scarce use of innovative research
techniques and approaches for enabling us to better grasp the
underlying complexities in this challenging field. Hopefully
this book will be an inspiration for younger researchers to
move the research agenda forward.
In conclusion, I would like to thank all those who have
contributed to this publication, especially the writers and
the conference participants who gave comments. Special
thanks go to Dr Rosalia Sciortino, Regional Representative
of the Rockefeller Foundation, Bangkok Regional Office who
contributed valuable advice and encouragement. I am also
very grateful to Virginia Henderson and Eveline Yang who
edited the English and Atik W. Indriati from Surviva Paski
for preparing the layout and organizing the printing of this
publication.

Zhang Kaining
Institute for Health Sciences
Kunming Medical College, China
Talking Sex:
Anthropological
Narratives
in Sexuality
Research
Talking Sex:
Anthropological Narratives
in Sexuality Research
Michael L. Tan
Generating Narratives
A short methodological note will be useful here, given that

people will be asking: So how do we do narratives?
I would say narratives aren’t “done”; instead, they

are generated. A good researcher sets the conditions that
allow narratives to be elicited. New researchers are often
intimidated by the word “narratives,” thinking it must be
some fancy research method requiring intensive training. But
narratives are really nothing more than focused stories, elicited
from and elaborated by people much like conversations.
Many of the qualitative research techniques–individual
interviews, group interviews, life stories–have the potential
for allowing narratives to emerge. However, as in the case of
the first narrative below, sometimes narratives are generated
spontaneously. They can emerge, too, in casual conversations.
In understanding how narratives are generated, we see that
the narratives are there to strengthen other research methods,
allowing us to pick up on new themes or to elaborate on old
ones. Narratives are different from structured interviews. They
depend on using an outline or a guide with specific topics to

explore, but they also take on a more conversational tone. The
person being interviewed is less an informant or a respondent
than a conversational partner, engaged in storytelling and
reflection. It is this loose structure that allows narratives to
yield rich data, allowing researchers to “explore the ways in
which people understand and plot their lives.” (Kirkman,
Harrison, Hillier, & Pyett, 2001, pp. 279-294). In the cases I will
present, we will see that it is not just “lives” being plotted out
but risks, vulnerabilities, dangers, and pleasures as well.
I would like to share two narratives that reflect the
complexities of sexuality and sexuality research. In doing
so, I hope to show what these narratives can do in terms of
producing insights into sexuality.
Tonio, a Taxi Driver
I’ll start off with Tonio, a taxi driver in his thirties. His story
was not something I obtained from formal research. I had
gotten into the taxi at Manila’s airport and the taxi driver was
in a particularly talkative mood. As he talked about his life
as a driver, I realized that there was much in his stories that
was useful for understanding masculinity and sexuality in the
Philippine context. I did not bring out a pen and paper while
he was telling his stories, but I took notes down immediately
after the trip and I consider his narrative to be one of the most
useful I’ve ever gathered. Let me share some of the highlights
of his story.
Tonio started off by talking about how difficult it was
to earn a living: “Hirap ng hanap-buhay ngayon.” He described
Talking Sex: Anthropological Narratives in Sexuality Research
the long working-hours that he had to put in. “Alanganin

[Everything’s uncertain],” he said, referring to the work. There
were, he said, risks of robberies and more. He shifted to talking
about women passengers; the ones who would hail down the
taxi at odd hours. He was clearly referring to sex workers. With
such passengers, he said, there were many “happenings” and
“gimmicks.” I realized that the theme of danger and risk was
now converging with that of fun and pleasure. Some of the
passengers, he said, would offer sex for payment while others
would offer a bit of aliw (pleasure], instead of paying the taxi
fare. “Lalake naman ako [I’m only male],” Tonio replied when
I asked him how often he’d accept sex for fare.
Tonio had started the conversation talking about risks,
so I thought of connecting our conversation to safer sex; I
asked about condoms. Tonio practically dismissed the risks
involved, claiming he never had sex in the taxi. After all, he
said, doing it with a sex worker in the taxi would bring malas
(bad luck). In fact, he said, simply having the sex worker in his
cab could already bring bad luck in terms of fewer or even no
passengers for the rest of the day. So while dismissing sexual
health risks with the female sex workers, Tonio was actually
describing the sex workers as risks in themselves. It is an old
theme, of course, of women being almost “naturally” defiling
and bringing misfortune. This view of women becomes more
frankly misogynist when it is applied to sex workers, seen as
carrying malas or misfortune in and of themselves.
There is ambivalence in these perceptions; an interplay
between the perceptions of the women as objects of pleasure
as well as bearers of danger. In the end though, Tonio admitted
that he would occasionally have sex with the sex workers in

the cab. There were practical considerations here: Motels, he
explained, were expensive, so why not just do it in the cab?
Again, he was quick to explain that these encounters in the
cab were limited to mutual masturbation. “Para ligtas [To play
safe],” he explained, he would take antibiotics. Moreover,
he said that after these encounters, presumably because his
hands would come into contact with the sex workers’ genitalia,
he would use a rather unusual antiseptic: brake fluid. I was
startled. This was the first (and last) time I was to hear of
brake fluid being used to ward off infection. But our rather
imaginative taxi driver had an explanation about why he was
using brake fluid: If it was strong enough to stop a car, then
it should be strong enough to prevent a sexually transmitted
infection. Here was a narrative shedding insights into popular
culture and logic. We could dismiss it as illogical, but what
else could have epitomized, for a taxi driver, the notion of
strong efficacy?
The conversation didn’t end there. Eventually, he
reached for the sunshade above his head and pulled out a
condom. He seemed almost proud to show me he was always
prepared, saying, “Laging handa,” in a tone that reminded me
of the Boy Scouts’ motto. He would use the condoms, he said,
if he ever went all the way with the women in motels. I was
realizing that this driver was quite a Lothario, actually fitting
into the stereotype of the malibog (sexually promiscuous) taxi
driver. Here was someone who was almost typical in the way
he would boast about his sexual adventures.
I finally asked him if he had ever had any sexually

transmitted diseases from all his encounters. He did recall
one particularly long episode, a paulit-ulit (recurring) series
of what he labeled as tulo (literally, a “drip”), referring to a
disease with penile discharge. He had picked up a female
sex worker who then, he claimed, gave him the infection. He
then passed on the infection to his wife, who was pregnant at
the time. Initially, he did not tell his wife about his infection,
but he knew that she had gotten infected and that she was
self-medicating. Apparently, his wife didn’t know she had a
sexually-transmitted infection and probably treated herself for
urinary tract infection. Not surprisingly, she wasn’t getting
any better. The cab driver, on the other hand, had been using
a tetracycline antibiotic and, again with full male bravado, he
said he knew the medicine was effective because he had used
it many times before. But he wasn’t getting any better either
because his wife kept re-infecting him. He was now caught
in a rather odd dilemma: How was he going to get his wife
to take the tetracycline antibiotic in order to break the cycle
of infection? In the Philippines, there is a popular medical
culture of identifying particular medicines with particular
diseases. Antibiotics, in this context, would easily be read as
a remedy for sexually transmitted diseases. Therefore, the taxi
driver knew that if he asked his wife to take the antibiotic, he
would have to admit he had started the infection. A wife, of
course, is always presumed to be totally loyal and faithful, and
now she would find out that her feckless husband had been
playing around. In the end, the taxi driver found a solution.
He told his wife he had indeed acquired a sexually transmitted
disease. But to cushion the blow, he never admitted that he

had gotten it from a female sex worker. Instead, he blamed it
on a passenger he had picked up, a bakla (loosely translated
as “homosexual”).
Here again was another insight into the sexual culture
of taxi drivers. Part of the sexually promiscuous stereotype
of a taxi driver is the idea that they will have sex with
anyone: female, male, bakla. Tonio was capitalizing on this
stereotype. Not only that, he was counting on the notion that
an extramarital fling with a bakla, a homosexual, would have
been more acceptable to his wife than if he had admitted to
an affair with a female sex worker, or any woman for that
matter.
There is a whole constellation of sexual values interacting
in this case, with ideas about gender, about risks and pleasure,
and even about morality.
Veronica, a Housewife
Let me move now to the second narrative, this time gathered

by one of my co-researchers during research conducted in 1996
about family planning. Our interest in that research project
was perceptions about family planning, including particular
family planning methods.
One of our research subjects was Veronica, aged 24 years

at that time, and a housewife from a poor, urban community.
The interviewer had started out with the usual questions
about demographic details (e.g., age, civil status, number
of children), followed by a question about whether she was

using any family planning methods. Veronica answered that
she was on the injectable contraceptive Depo Provera. The
interview continued with Veronica explaining why she was on
family planning: “Mahirap ang buhay [Life is hard],” she said,
a sentence she was to repeat several times in the interview. It
had been difficult finding work, she said, and she had frequent
fights with her husband.
The interview struggled, with the researcher trying to get
Veronica back on the subject of family planning while Veronica
kept going into her personal difficulties. After awhile, the
researcher realized that Veronica’s reference to a difficult life
related to domestic relations as well. The researcher allowed
Veronica to lead the discussion, letting the interview turn into
a kind of autobiographical narrative. Eventually, she blurted
out, “Ayokong mabuntis. Kahit mabulok ang matris ko [I don’t
want to get pregnant, even if my uterus rots].” This was when
the researcher realized the full extent of Veronica’s domestic
problems. Veronica was, in effect, willing to put herself at risk
with the perceived dangers of Depo Provera–the idea that
one’s uterus might “rot.” As far as she was concerned, this
risk was preferable to getting pregnant again by a husband
she loathed.
The interview did not end there. Veronica shifted the
discussion to religion; of how she had become a born-again
Christian and how she had rationalized that God would
forgive her for using contraceptives (a reference to the Roman-
Catholic ban on using “artificial” methods). The researcher
then asked Veronica if she really even wanted family planning.
Veronica repeated that she didn’t want to get pregnant, even

if her uterus would rot away.
Again, while the interview seemed to trail off, it
suddenly picked up again as Veronica talked about how
difficult pregnancies had been. There was a detour in her
narratives back to religion, then to her children. “Pangit ang
buhay ko [My life is not good],” she said, and she went into her
turbulent marriage. “Kaya ako nag contraceptives [That is why
I used contraceptives],” she now makes a direct link between
the contraceptives and her unhappy marriage. “Ayoko na
talaga [Really, I don’t want ‘it’],” Veronica said. It is not clear
what she does not want, although our analysis suggests it is
a general despair–unhappiness with the marriage, with the
contraceptives, and with her family.
On the surface then, Veronica’s narrative is about
contraception, but the text reveals many deeper themes of
self, of personhood, of masculinity and femininity, and of
guilt and anger. Her story shifts family planning to a broader,
painful discourse of gender relations, marriage, and religion.
The interviewer ended that session with Veronica by asking,
“Is this your decision?” referring to the use of Depo Provera.
“Desisyon ko ito [This is my decision].” Veronica answered in
the affirmative.
What Do Narratives Have to Offer?
In sharing these two narratives I had hoped to show what

personal stories could do for research. But to underscore the
potentials in eliciting narratives, I would first ask: What might

other research methods have yielded, if applied to Tonio and
Veronica?
A survey questionnaire answered by Tonio would have
told us that this taxi driver uses condoms occasionally. A survey
administered to Veronica would have counted her as someone
using family-planning methods, someone using Depo Provera.
If we had gone a step further, using a structured interview
with fixed questions, we probably would have acquired a bit
more information. We probably would have found out that
Tonio had multiple sexual partners. A structured interview
would have allowed us to probe a bit into Veronica’s life, and
the interviewer would have come away with information that
she was a housewife who planned her family because “life was
hard,” interpreted mainly through economic terms.
In general, qualitative research is more useful in
revealing the motivations behind actions and behaviors.
Narratives are among the most powerful tools in qualitative
research, bringing out not just people’s motivations but a
whole range of feelings and subjectivities, including the way
those emotions shift as people deal with the world around
them. Thus while we empathize with Veronica’s plight, we
also see glimpses of agency; the attempts to confront problems.
While we may feel frustration with the limited agency that
is available to Veronica, that too is important in research; the
ability to recognize both the potentials and limitations in
what people are able to resort to. Narratives, as Tonio’s and
Veronica’s demonstrate, tell us that culture isn’t a coherent
whole; culture, especially sexual culture, is not a coherent
whole. Instead, culture is full of ambiguities, conflicts and
tensions. Showing the contradictions and paradoxes reminds
us that “interventions” and behavioral change are not as
simple as they are often depicted to be. Behavioral change
occurs in social contexts, complicated maze-ways, like what
we saw in Tonio and Veronica’s lives.
If you were to read through the transcripts, you would
find yourself adopting an insider’s view into the way people
configure and reconfigure their identities in relation to the
world around them, and the roles assigned to them. We saw
gender roles played to the hilt by Tonio and Veronica.
In Tonio’s case, we obtained a glimpse into machismo
with its themes of risk-filled conquests, the maneuvering–
however hapless and futile as in the case of the brake fluid–
around the perceived risks, and the tremendous structural
and institutional constraints that amplified those risks. We
may be angered by the deception of Tonio’s wife, but one
also needs to ask, “Why is there such a lack of available
information that would allow Tonio, his wife, and even
their unborn child to be at such risk?” In Veronica’s case,
the interview gave her an opportunity to reflect on her life;
the “hard life” first sketched out in broad strokes, and then
the harsh details that later emerged. Family planning and
contraception retreated into the background, as we learned
to understand the plight of women like Veronica, with the
powerful imagery of choosing between Depo Provera and
carrying her husband’s child–the latter being the worse evil.
Veronica’s story evoked the notion of chi ku in Chinese–of
“eating bitterness”–a term used often by women to refer to
the kind of silent suffering they must endure.
As an anthropologist, I have found narratives to be

essential to research. Narratives allow us to fine-tune what
we have, forcing us to be more discerning even during the
research process itself. Veronica’s narrative was so rich
because our interviewer was sensitive enough to “let go,” to
set aside interview protocols to allow Veronica to speak out
and take the necessary twists and turns in subject matter as
she reflected on her situation.
Narratives are drawn from “real” situations, from
the way people actually deal with problems and issues.
This is why the data from the narratives can become very
useful for programs. In my work with non-governmental
organizations, narratives have been “thrown back” at people
in workshops to see how they respond. For example, using
Tonio’s experiences, we have asked different groups if indeed
an extramarital fling with a bakla, rather than another woman,
is more acceptable to a wife. The responses have been varied,
with different reasons given.
A bakla is preferable because he can’t get pregnant.”

A bakla is more threatening because you start to
wonder about your husband’s sexual orientation.
A woman sex worker, maybe yes, because there
would be no love developing.
In effect, narratives generate further narratives and
insights.
One could ask, of course, if narratives do not often
include exaggerated accounts, or outright “lies.” I would
respond by saying that lying occurs even in the most
controlled surveys. Only an incompetent scientist would claim
that the statistics generated in surveys are exact reflections

of “truth” or “reality.” In qualitative research, especially in
the use of narratives, we do not lay claims to extracting the
absolute truth. Instead, the narratives are meant to reveal
the meanings people have and the ways they negotiate with
those meanings in the context of their lives and people around
them. Certainly, we are less interested in whether brake fluid
destroys gonorrhea germs than the notion itself of brake fluid
being “strong” and “effective.” Likewise, we would never
infer from Veronica’s narrative that Depo Provera is useful
for dealing with a problematic marriage. Instead, her story
is powerful because of the metaphors of risk–the risks she
weighs between using Depo Provera and becoming pregnant
by a husband she detests.
To end, I will add that narratives become, in themselves,
“interventions”–almost therapeutic in a sense as we saw with
Veronica. Initiating a session with narratives is a powerful
authorization, often of people who are marginalized, to speak
out and to articulate many thoughts that were previously
kept private.
Note how I have used verbatim quotes in Filipino, the
language used in the interviews. I believe that if narratives
are useful, it is because it brings out the richness of the human
language. For words to convey their full meaning, we need
to be able to go back to what was actually said, in its original
language. This is at the heart of the narrative: words and
quotes in verbatim.
A few months back I had to sit at an anthropology
dissertation defence that I found particularly flat and dull.
I finally asked the student where the anthropology was, in

terms of the dynamism that surrounds people’s concepts and
views. I pointed out that there were few direct quotes from
people to give us insights into what they were thinking about
and how they were processing the world around them. What
was so terribly depressing was the response of the advisor:
“Oh, I asked her to take out the quotes from people. They
were only narratives.”
Only narratives? The strength of research lies in the way
it brings out substantive information in its full context. True
science, rigorous science, must allow that context to emerge
and this is where narratives play a vital role. Where people’s
voices are muted, one cannot speak of research in the social
and human sciences.
Acknowledgement:
This article is a modified version of a presentation given at the 6th Asia-Pacific Social
Science and Medicine Conference, October 14-18, 2002, Kunming, China.
References
Kirkman, M., Harrison, L., Hillier, L., & Pyett, P. (2001). “I know I’m doing
a good job”: Canonical and autobiographical narratives of teenage
mothers. Culture, Health, and Sexuality, 3(3), 279-294.
✤✤✤
Representations
of Gender
and Sexual
Identity
in Research
Representations of Gender and
Sexual Identity in Research
Suchada Thaweesit
The Theoretical Lens
This paper focuses on a particular theoretical framework for

researching gender and sexuality. Specifically, it is intended
to show how a discourse analytical framework is useful in
identifying the nature of gender and sexual subjectivities
that women tend to express in their narratives and self-
presentations. This theoretical framework emphasizes that
subjectivity is “precarious, contradictory and in process,
constantly being reconstituted in discourse in everyday life”
. It is, moreover, “conscious and unconscious thoughts and
emotions of the individual, her sense of herself and her ways
of understanding her relation to the world.” (Weedon, 1997,
p. 32)
The term discourse used in this analytical framework
refers to “a group of ideas or patterned way of thinking
which can be identified in textual or verbal communications,
and can also be located in wider social structures” (Powers
1996, p. 209). Sociologically, discourse is the way in which
a person connects his/her thoughts and understandings
about both the social and physical in language forms. A
person uses language in everyday life to construct, pass on
and reinforce knowledge about the world. Two types of

discourses govern our social lives. The first, authoritative/
institutionalized discourses, include both long-standing and
recently-established discourses. These may be, for example,
social values, social norms, social ideologies, family planning
campaigns, HIV/AIDS prevention messages, commercial
advertisements, etc. The second, individualized/personalized
discourses, include personal desires, personal judgments,
personal critical thinking, etc.
Discourse always combines with the technologies of
power such as the media, workplace, legal system, religion,
school, family, etc., which themselves are the products of
discourses, to shape the subjectivity and behavior of the
person (Foucault, 1977). The discursive forces among which
an individual is caught are often incoherent and contradictory.
Due to the fact that the individual has been brought up
with a system of multiple meanings, which sometimes may
contradict each other, the individual is always the site of
conflicting forms of subjectivity. The positioning of the subject
in multiple choices of discourse makes the subjectivity of the
individual even more fluid and unstable. In the same vein, a
fluidity of subjectivity causes a person’s self-representations
to be unstable, incoherent, and conflicted.
Based on this framework, we can see that discourses
interact with power and the technologies of power such as the
religion, families, the mass media, and medical institutions,
etc. to create sets of knowledge about gender and sexuality.
Moreover, discourses can be both instruments and effects of
power which also have social power and authority in creating
Representations of Gender and Sexual Identity in Research
a person and his/her subjectivity, such as by making gendered

categories called men and women. Discourses subject both
men and women to the social values, norms, and ideologies
they have conveyed.
Figure 1: Discourse Analytical Framework
discourses interaction of knowledge about

discourses and gender and
power within sexuality
social institutions
power
passed on and
reinforced
through social
institutions
a person’s gender and

sexual subjectivity
a fluidity of subjectivity
a person’s position
and self-representation
in conflicting and
competing discourse
Sources of Data
The analytical framework above is explained by drawing

on cases in my ethnographic study entitled From Villages to
Factory “Girls”: Shifting Narratives on Gender and Sexuality
in Thailand (Thaweesit, 2000). That study aimed to answer
the research question: “What is it like to be a woman in the

context of socio-cultural and economic changes?” Research
fieldwork was conducted between 1997 and 1998 and the
primary respondents were young women who largely came
from villages and worked in factories in Thailand’s biggest
multinational industrial park, located about 46 kilometers
from Bangkok. Throughout the fieldwork, I compiled
women’s narratives, life histories, statements and dialogues
as well as observed their behaviors, sexual relationships,
lifestyles, sexual orientations, and responses to the AIDS
crisis.
Interpretation and Discussion of Data
Case 1. Negotiating premarital sex (a 21-year-old woman)
If I had the choice, I wouldn’t want to have any kind of sexual intimacy
with my boyfriend. I want to get to know him better and want to see
what kind of a person (good or bad) he is for a while. But I know my
wish is very unrealistic. If I don’t allow him to even touch my hands, no
man will want me to be his girlfriend. I think I would go with number
two–touching hands is okay for me. But I wouldn’t allow him to hug
or kiss me. Hugging and kissing are no different from having sexual
intercourse. If you allow your boyfriend to hug or kiss you, surely he
will think that you will allow him to have sex with you. Also, it’s not
easy for a man and a woman to stop at just kissing and hugging. They
usually end up sleeping together after that. I believe that if a woman
lets her boyfriend kiss and hug her, she has already gone half way. For
me, if I let my boyfriend kiss and hug me, it means that we plan to get
married and my parents know about our plan. I don’t think that it is
improper for fiancés to kiss and hug one another.

As shown in the statement above, this young woman was
ambivalent towards physical contact with a man. Her
ambivalence stemmed primarily from the strong customary
discourse in Thai society that prohibits physical contact
between the opposite sexes, especially between sexually
mature males and females who are not siblings or cousins.
Within this long-established discourse, physical contact
between the sexes is considered a sign of sexual intimacy
or an expression of sexual interest, which is not allowed for
lovers who have not yet married. At the same time, there are
other sets of authoritative discourses concerning women that
encourage Thai women to seek a husband. In Thai society, a
daughter’s marriage is a central parental concern. Marriage is
seen as an extremely important rite of passage which provides
women with social status. This type of well-established
discourse has been further supported by popular myths,
which is another dominant discourse about never-married
women.
While the traditional discourse upholding marriage
remains intact, the proliferation of romantic stories in popular
culture productions is also aimed at female audiences.
Love songs, music videos, movies, soap operas, novels and
magazines that contain messages of romance encourage
young women to long for romantic companionship and
marriage. Very often, these popular discourses promote a
more liberated sexual freedom for women. Thus, the ultimate
objective of most young girls is to fall in love and to be married.
Although today more Thai women see marriage as optional,
authoritative discourses regarding marriage and romance

continue to play an essential role in the production of women’s
subjectivity regarding sexuality. Authoritative discourses
themselves convey conflicting messages to women. While
the discourse of “no physical contact” discourages women’s
expression of sexual intimacy with men and premarital sex, the
discourses of “should marry” and “falling in love” somehow
encourage the opposite. These contradictory messages are
complicated further by young women’s deep and compelling
emotional desires.
This young woman also listened to her own consciousness
and desires (which I call “individualized discourses”). Fears
of losing a boyfriend and losing the chance to marry motivate
young women to reconsider the boundary of permissible
sexual intimacy with men. Women are aware that Thai men
in general want to have intimate sexual relations with their
girlfriends. A refusal to engage in intimate sexual relations
with a boyfriend or fiancé may cause a man to walk away
from a relationship. Women also know that if they want to
marry at all, some degree of relaxation regarding sexual codes
must be granted to a man. They believe that more flexibility
in intimate sexual relations will allow them to establish a
relationship with a man of their affection, thereby enhancing
their chance to be married.
I argue that women’s negotiation with these competing
discourses provokes tension and fragmentation in women’s
thinking process, thereby resulting in an uncertainty of
their self-representation. As shown in this young woman’s
statements, in order to be able to negotiate, she opted to
allow some lenience in the sexual intimacy that she said she
would have with her boyfriend. She stated that she found it
acceptable if her boyfriend touched her hands, but kissing or
hugging were not allowed. Interestingly, when asked, “If your
boyfriend tried to persuade you to have sex with him as proof
of true love, would you consider having sexual intercourse
with him before your wedding?,” she answered as follows:
It would depend on the circumstances. If we

were sure that we would marry in the end, which
means that he had already come to tell my parents
that he would marry me, it would be OK to have
sex with him before the marriage.
According to this excerpt, this young woman would allow a

greater degree of sexual intimacy and even intercourse if her
boyfriend made a commitment. This case indicates that there
is a multiplicity of discourses concerning sexual intimacy and
premarital sex being expressed and negotiated by women.
These discourses also illuminate the way in which a woman
turns the power of authoritative discourses inside out to
benefit herself. She is able to use authoritative discourse to
negotiate and persuade a man to take on the responsibilities of
a relationship by committing to marry her. For a Thai woman,
a committed relationship is established only when a boyfriend
becomes her fiancé or when he declares his commitment to
her parents. A committed relationship requires a change in
subject position for both the man and the woman.
Analysis of Case 1
Conflicting dominant discourses Fluid subjectivity
• Prohibit premarital sex. • If I had the choice, I
• Encourage women to get wouldn’t want to have
married. any kind of sexual intimacy
• Encourage women to seek with my boyfriend.
romantic love. • If I don’t allow him to
even touch my hands,
Norman will not want
me to be his girlriend.
Touching hands is okay
for me.
• If I was sure that he would
marry me in the end, it
will be OK to have sex
with him before marriage.
Case 2. Negotiating sexual and asexual self (a 27-year-old

woman)
Being a woman means being everything, especially for her family.
A woman must be a good mother and a good wife, taking good
care of her kids and of her husband. Being a good wife means being
good in bed too. If a wife can satisfy her husband, especially in
bed, the husband will not go out to look for other sexually-skilled
women for satisfaction. He will stay at home because he is able
to get it from his wife. Sex is a very important aspect of family
life. A husband who is not satisfied sexually by his wife is likely
to find other women who can satisfy him–and that’s dangerous
for the wife, since he might bring AIDS home. So wives should
learn sexual skills in order to please their husbands. They should
cooperate with their husbands if their husbands want to try out
new sexual techniques. Most men discuss sexual matters with
their friends. Sometimes, they learn about new from friends and
want to try them with their wife. If a wife refuses to cooperate, a

husband might try the new techniques with prostitutes.
In light of the AIDS crisis and the country’s nationwide

HIV/AIDS campaigns, Thai women are encountering
bewildering messages. One message suggests that non-sexual
women are “bad” because they may fail to protect themselves
and their families from AIDS. Another message advises that
good wives should become sexually skilled and responsive
in order to fulfill their husbands’ sexual fantasies and thus
prevent them from going astray and bringing AIDS home.
Apparently, the image of sexually-skilled women starkly
contrasts with the image of the non-sexual “good woman”
epitomized by the identities of mothers and wives. This
excerpt suggests that, in the wake of the AIDS crisis, women
feel that it is important for “good women” to cast themselves
as “sexually-skilled women.” The contradictory messages
pose a problem for women in identifying themselves because
they are required to become “good” and “bad” women
simultaneously. In this way, the clear boundary between
“good” and “bad” women is smashed. Yet what is striking in
women’s speech about sexual relations with their husbands
is the absence of the women’s own sexual needs. This is in
large part due to the well-established discourses of gender
and sexuality that limit and view female sexuality as passive,
reluctant, and merely responsive to male sexual urges.
Most female respondents in this study expressed an
acceptance of the idea of a “natural” difference in the needs
and sexuality of men and women. Some respondents spoke
of sex as something that they did not enjoy. A Thai woman’s
gendered identity both in the past and present has been
defined by her sexual virtues. Thai society’s “good” woman
or “bad” woman stereotypes are in large part the yardsticks
of acceptable sexual expression for women. Both married and
unmarried respondents said that it would be inappropriate
if a wife talked a husband into having sex with her. As they
commonly phrased it, “Women are not brought up to initiate
sexual activity. If a woman explicitly told her husband that
she wanted to have sex with him, he might think that she was
an oversexed woman and might look down on her. Women
should not overtly display their sexual needs.”
At the same time, one respondent stressed that sex
between a husband and wife plays a pivotal role in forging
and maintaining the marital bond. She talked about her own
sexual life in terms of responding to her husband’s sexual
desire. Many respondents referred to making love with their
husband as one of the many duties that wives must perform
for their husbands. They said that they sometimes indirectly
initiated sex by using subtle or indirect approaches such as
Analysis of Case 2
Conflicting dominant discourses Fluid subjectivity
• Asexual women are “good • Wives should be sexually
women.” skilled women to sexually
satisfy their husbands
• Asexual women are • It would be inappropriate
“bad women.” for a wife to persuade
her husband to have sex
with her.
• Making love with my
husband is a duty but not
my need.
embracing their husbands, knowing that this gesture would

arouse their husband’s sexual desires. They also said that if a
wife sexually satisfied her husband, he would not flirt around
with other women or sleep with prostitutes. The intention to
improve their sexual relations with their husbands is apparent
in the narratives of several respondents.
It is clear that the socio-cultural and economic contexts in
Thai society have shifted dramatically and continue to do so.
Three interrelated socio-cultural and economic contexts have
emerged and affected women’s lives in the twentieth century
and in present-day Thailand. These are: industrialization,
the reproductive revolution, and the AIDS crisis. Thailand’s
industrialization is marked by the feminized trend of rural-
to-urban migration in which women account for between 70
to 90 percent of migrant workers. The country’s reproductive
revolution is observed through married women’s far-reaching
use of modern contraceptives and the sharp decline of fertility
rates. The current AIDS crisis is indicated by increasing
numbers of AIDS patients and deaths. These contexts have
provided new discourses or language for Thai society and Thai
women in particular to rework, to negotiate, and to challenge
the gender identities and sexuality that have been promoted
in Thai society (through long-standing institutionalized and
recently established discourses). Because of these contextual
and discursive changes, it is necessary for researchers in the
fields of women’s gender and sexuality to take into account
the fluidity and complexity of gender and sexual identities.
They also must critically interpret the meanings of women’s
self-representations.
In Thailand, long-standing institutionalized or

authoritative discourses regarding women have played an
important role in shaping the past and present definitions
of Thai womanhood. I suggest that the reconstitution of
Thai women’s sense of gender and their understanding of
their sexuality are constituted both by new authoritative
discourses and by women’s own desires or agency. However,
the ethnographic data provided here suggests that the
reconstitution is more complex than we might imagine. This
is because the multiple and changeable subject positions of
women entail a complex web of competing authoritative
discourses as well as women’s own desires. This condition
requires women to negotiate their decisions, in order to
privilege certain kinds of discourses in specific circumstances.
In this paper, I tack back and forth between analyses of
women’s narratives and the normative or authoritative
discourses that govern women’s statements and behaviors.
Discourse Analysis and Challenges in Researching

Gender and Sexuality
Discourse theory is useful in analyzing Thai women’s

sense of gender and sexuality in several ways. It offers
insights into why Thai women tend to talk about their
gender identity and sexuality in sometimes ambiguous,
contradictory, and incoherent terms. It helps identify the ways
in which ideologies regarding female identity and sexuality
(institutionalized discourses) are maintained in Thai society.
It also helps uncover women’s consciousness and desire to

resist the normative ideologies imposed upon them via the
use of language. However, while it is necessary to understand
sexual behaviors as they are governed by discourses, women’s
verbal expression mapping out their sexual subjectivity should
not, of course, be isolated from women’s actual behavior
itself. The great discrepancy, and sometimes contradiction,
between ideologies and actual behaviors in the domain of
sexuality is often observed in anthropological sex research.
This has most certainly been the case with the sexuality of
several respondents.
Nonetheless, I posit that the contradiction between
actual behavior and sexual norms illustrates the political
importance of the role of discourse in domesticating, limiting,
controlling, or negatively depicting the behavior that needs to
be brought into line with authoritative discourses–discourses
that produce a “proper” gendered body of women. We also
need to take into account the essence of women’s verbal
silences and lying regarding their sexual practices, to further
explore women’s resistance to authoritative discourses
regarding female gender identities. Moreover, notions of
discourse and subjectivity refute the popular view that Thai
women’s gender and sexual subjectivity is coherent and
dichotomous: as good versus bad, or modern versus traditional.
The ethnographic accounts presented in this paper indicate
that Thai factory women negotiate modern subjectivities by
refusing or suspending traditional ones. Although it is not
necessary for Thai women to forever discard these older
subjectivities in order to assert new ones, negotiating between
them spawns a tension that women feel. Ambivalence and

tension predominate in women’s verbal expressions and
silences whenever their actual sexual behavior is incongruent
with certain authoritative or ideological discourses.
To summarize, in researching gender and sexuality,
there are several challenges offered by discourse analytical
framework. First, it helps a researcher to critically look at the
way in which social values, norms, and ideologies regarding
gender identities and sexuality have been constructed. Second,
it illuminates the language that constitutes social values,
norms, and ideologies which often subordinate women within
the system of patriarchy. Third, it offers a lens through which
to see social values, norms and ideologies regarding gender
and sexuality as sets of knowledge that should not be treated
as fixed, but which can be changed, to benefit men, women,
and homosexuals equally. Fourth, this framework helps a
researcher to understand and accept the existing differences
of practices and beliefs regarding gender and sexuality that
vary between cultures and individuals. Finally, the concept
of fluid subjectivity in discourse analytical framework
enables a researcher to breakdown traditional dichotomous
constructions of women’s gender and sexual identities, such
as, “good women” versus “bad women,” “modern women”
versus “conservative women” and “appropriate” versus
“inappropriate” sexual practices.
References
Foucault, M. (1977). Discipline and punish: The birth of the prison. (A.M.
Sheridan-Smith, Trans.) Harmondsworth: Penguin.
Powers, P. (1996). “Discourse analysis as a methodology for nursing
inquiry”, Nursing Inquiry 3, 207-217.
Thaweesit, S. (2000). From villages to factory “girls”: Shifting narratives on
gender and sexuality in Thailand. Unpublished doctoral dissertation,
University of Washington.
Weedon, C. (1997). Feminist practice and poststructuralist theory. Malden,
MA: Blackwell.
✤✤✤
Gender and
Sexual Health
of Adolescent
Females
in Northern
Thailand
Gender and Sexual Health
of Adolescent Females
in Northern Thailand
Arunrat Tangmunkongvoraku
and Pratima Bhuttarowas
Introduction
There is increasing evidence in Thailand of changing sexual

norms among young people. In numerous studies, large
proportions of young males and significant minorities of
young females report premarital sexual experience (Chaipak,
1987; Chanakok & Juntarawijit, 1993; Koetsawang, 1987;
Nuchanart, 1988; Puthapuan, 1994; Srisupan et al., 1990;
Thevadithep et al., 1992). Despite evidence of risky sexual
activity among unmarried youth, community norms and
attitudes remain conservative and the topic of adolescent
sexuality remains sensitive among adolescents themselves as
well as among parents and healthcare providers.
Gender double standards persist. Premarital sex continues
to be considered unacceptable for “respectable” women and
highly damaging to the reputation of the young woman and
her family. In contrast, premarital sex is widely acceptable
for young males; men are expected to have a strong sexual

drive that demands “release,” and unlike young women, it
is virginity for young males that is perceived as unacceptable
(Soonthorndhada, 1992). Attitudes toward contraception and
condoms are also polarized. Young women would like to know
more but are afraid that seeking or requesting contraception
will disclose their sexually-active status and subject them to
stigmatization. In contrast, condoms are more widely available
to young males, but are used irregularly in contacts with
sex workers and rarely in relations with girlfriends. Despite
these patterns, contraception is viewed as the women’s
responsibility (Saiprasert & Ford, 1993).
Concern about the sexual and reproductive health
of young people has been expressed at the national level.
Recently, a Working Group on Population Policies and
Development Strategies underscored the need to address
the sexual and reproductive health needs of young people.
It noted that unplanned pregnancies, unsafe abortion,
STDs and HIV, sexual violence, alcohol and drug abuse,
and unsafe sex practices among youth were increasingly
observed. It also identified leading obstacles as; a lack of
sexual and reproductive health awareness, limited life skills
(e.g., negotiation skills), the persistence, at the family and
community level, of traditional norms about premarital sex
and reluctance to discuss sexual matters. In short, the Working
Group recognized the role that unequal gender relations plays
Gender and Sexual Health of Adolescent Females in Northern Thailand
in compromising safe premarital sexual behaviors among Thai

youth (National Commission on Women’s Affairs, 1999).
Gender double standards have a considerable influence
on the sexual and reproductive health and lives of young
people. Young females bear the brunt of this, in terms of
limited decision-making in sexual partnerships, limited
practical access to contraceptives, counseling, and other
services, as well as the risk of pregnancy and HIV. Yet few
studies have explored the ways in which gender disparities
and double standards have pervaded interactions between
young females and healthcare providers, particularly in the
northern region of the country.
The objective of this paper is to fill this gap in knowledge
about gender double standards and the ways in which these
act as obstacles to the attainment of sexual and reproductive
health services in Thailand. It focuses specifically on youth
partnerships and service provider attitudes and perspectives
on working with unmarried youth. Data drawn from a
qualitative study in northern Thailand intends to shed light on
the experiences and perspectives of both the youth themselves
as well as service providers, with regard to obstacles to safe
and wanted sex and sexual health services for unmarried
young females and males. Findings are intended to guide
the development of sexual health services for young people.
Background
Thailand’s population of 60 million is spread over four

geographic regions and 76 provinces. This study was based
in Chiang Mai, the northern regional capital, and Lamphun, a

small province located 30 kilometers away from Chiang Mai.
The large majority of the population is Buddhist (95 percent)
and most people speak both the northern and central Thai
dialects. The northern region records the highest rates of
HIV infection in the country (Royal Thai Ministry of Public
Health, 1994).
Despite pervasive parental controls, it is clear that social
norms have changed and opportunities have expanded
for young people in Thailand. Young people enjoy social
interaction in mixed-sex company in schools, workplaces, and
entertainment spots (Yoddumnern-Attig, 1992). Compelling
evidence suggests that large proportions of unmarried Thai
youth are engaging in sexual activity, but at the same time that
huge gender double standards persist and that sexual activity
by young females, in particular, is strongly disapproved of
(Soonthorndhada, 1992).
A survey by Koetsawang (1987) on the sexual experiences
of college students in Bangkok (involving 1607 males and
1813 females) revealed that among students aged 19 years
or younger, 45.2 percent of male and 5.3 percent of female
students were sexually experienced. Among students aged
20 or older, 62.2 percent of males and 7.5 percent of females
were sexually active. Another study in Khon Kaen Province
in northeastern Thailand found that among vocational school
students aged 15 to 19 years, 62 percent of male and 12 percent
of female students were sexually experienced (Chaipak, 1987).
A third study in Suphanburi Province in central Thailand,
reported that 41 percent of male and 7 percent of female
students were sexually experienced (Nuchanart, 1988). Studies

in Chiang Mai suggest a largely similar pattern. Surveys,
using self-administered questionnaires, conducted among
adolescents in schools, colleges, and universities, found that
between 19 to 52 percent were sexually experienced (Chanakok
& Juntarawijit, 1993; Puthapuan, 1994; Srisupan et al., 1990;
Thevadithep et al., 1992). Although premarital sexual activity
continues to be higher among young males than females, the
gap is narrowing (Chaipak, 1987; Chanakok & Juntarawijit,
1993; Koetsawang, 1987; Natpratan et al., 1996; Nuchanart,
1988; Puthapuan, 1994; Rugpao, 1995; Srisupan et al., 1990;
Thevadithep et al., 1992).
The evidence also confirms that adolescent sexual
activity is largely risky and that in the past ten years the age at
sexual debut has declined (Koetsawang, 1987; Rugpao, 1995).
The age of sexual debut reported in studies of adolescents in
schools and colleges in Chiang Mai, for example, ranged from
15 to 19 years old, and over half of all males reported sexual
debut with commercial sex workers. Moreover, condom use
was irregular and rarely practiced in sexual relations with
girlfriends (Chanakok & Juntarawijit, 1993; Puthapuan, 1994;
Srisupan et al., 1990; Thevadithep et al., 1992; ).
Another study conducted among adolescent factory
students in Chiang Mai found that of 601 male adolescents
aged 16 to 21 years, 82 percent were sexually experienced
and most reported risky behaviors. The average age of sexual
debut was 16.5 years. For almost half, debut occurred with a
commercial sex worker and for another third, it occurred with
a casual partner whom the survey respondent did not expect
to marry. Condom use for sexual debut ranged from 20 percent

if the partner was not a sex worker to 54 percent if the partner
was a sex worker. Indeed, some 17 percent of young, sexually-
active males reported that their sexual debut occurred when
they were aged under 16 years and a condom was not used.
Thirty-three percent of male respondents reported multiple
partners within the past twelve months. Among the 609
female adolescents in this study, 42 percent reported sexual
experience, mostly within the context of marriage. However,
15 percent reported sexual debut with a man who was not a
husband and there was a low percentage of condom use (16
percent) (Rugpao, 1995).
Studies have also documented the adverse consequences
of risky sexual activity among young people. The rate of
teenage pregnancy has increased sharply in Thailand. Between
1989 and 1992, approximately 13 percent of all births were
to teenage women (the same as in the United States and
twice as high as that of the United Kingdom) (Brown, Fan, &
Gonsoulin, 1991; Kane & Wellings, 1999; Royal Thai Ministry
of Public Health, 1993).
Teenage mothers also tend to encounter more negative
psychosocial consequences of pregnancy than adult mothers,
including interruption of education, low self-esteem, economic
dependence, and loss of family, peer, and partner support
(Piyasil, 1998).
Alarmingly, high rates of HIV-1 infection were reported,
especially among pregnant adolescents attending one
Bangkok facility between 1991 and 1995 (Taneepanichskul,
Phuapradit, Chaturachinda, 1995). In Lamphun, a study of
industrial workers (with a mean age of twenty-two) found

that almost 4 percent of both female and male respondents
tested positive for syphilis (VDRL) and 6.6 percent of males
and 1.3 percent of females were HIV positive (Natpratan et al.,
1996). A second study conducted among a rural population
in the Chiang Mai area reported that 5.9 percent of males
and 3.3 percent of females were HIV positive. Additionally, a
study of young men aged under 21 years in military service
in northern Thailand reported that HIV-infection rates fell
from 11.4 percent in 1991 to 4.8 percent in 1996, but rose to
5.4 percent in 1997.
Despite these trends, sexual and reproductive health
counseling and services are not available, in practice, to
unmarried young people and, in particular, young females.
Although evidence from Thailand is sparse, research findings
from many developing countries suggest that unmarried
young females face a host of obstacles in their efforts to seek
information, counseling, contraceptive, and other sexual
and reproductive health services (Gubhaju, 2002; Mehra,
Savithri, & Coutinho, 2002; Tanmunkongvorakul, Sombatmai,
Ruangyuttikarn, & Bipodhi, 2002; Tu & Cui, 2002).
Prominent among these are individual and community-
level obstacles including embarrassment and fear of disclosure
of sexually-active status, misperceptions concerning
exposure to risk, and service and provider-level barriers. In
numerous studies, young women report that barriers such
as inconvenient clinic timings, lack of affordability, lack
of privacy, and, in particular, judgmental and threatening

provider attitudes have inhibited them from seeking services
(Gubhaju, 2002). Studies of providers, likewise, have largely
corroborated these perceptions of young people (Koff &
Cohen, 1983). Indeed, findings from Thailand suggest that
young people, both male and female, prefer to receive services
from drugstores than from clinics, despite the fact that advice
and care provided at both private clinics and drugstores are
perceived to be unsatisfactory (Benjarattanaporn et al., 1997;
Tangmunkongvorakul et al., 2002).
Data and Methodology
Data is drawn from a qualitative study intended to probe

adolescents’ access to services and providers’ perspectives in
addressing adolescent sexual and reproductive health needs
in northern Thailand. Conducted in 2001, the study examined,
through in-depth interviews, the experiences and attitudes
of a range of adolescents and providers concerning sexual
and reproductive health services. Findings are intended to
inform the design and planning of youth-friendly sexual
health services for young people in northern Thailand.
The sample comprised 82 adolescents (52 females and
30 males) aged 14 to 20 years, drawn from in-school and
out-of-school settings around the Chiang Mai and Lamphun
area. Young people were contacted at their places of residence
(e.g., flats and dormitories) and near places where they shared
activities together (e.g., restaurants, factories, schools, and
colleges). Many of the respondents were recruited at places

of recreation (e.g., pubs, bowling alleys, shopping malls, and
meeting points along city canals and at public gardens) where
a wide representation of in-school and out-of-school teenagers
from both rural and urban residential areas typically gathered.
Respondents were purposively selected and included
representation from those in and out of school, working and
non-working, and older and younger. The study deliberately
sought to over-sample those with sexual experience. Only
those who consented to participate were included.
The sample also comprised 44 healthcare providers
drawn from 15 diverse sexual health settings providing
services to unmarried youth, including governmental and
non-governmental (NGO) family planning centers, provincial
health offices, subdistrict health centers, STD clinics, and
anonymous HIV testing clinics located in the Chiang Mai
and Lamphun areas. Between two and five clinic staff were
interviewed at each site, including doctors, staff nurses, health
educators and social workers; a criterion for selection was
their involvement in delivering services to adolescents. In-
depth interviews were conducted by trained interviewers who
explained the objectives of the study and sought permission
to take field notes and tape the interviews. In some cases,
repeated interviews were conducted.
In-depth interviews with adolescents were usually
conducted over several visits. Respondents were asked
about their sexual experiences, attitudes, and awareness of
HIV infection, sexually transmitted diseases and pregnancy.
Contraceptive and other reproductive-health seeking
experiences, and the barriers or constraints faced in accessing

sexual health services were also explored. Providers were
asked about their experience in providing services to
unmarried young people, the nature of such services, the
barriers they met, their opinions about the possibility of
providing special services (clinics or outreach programs) to
sexually-active unmarried people and adolescents, and their
perceptions of what would make an ideal service.
Socio-Demographic Background
The 82 adolescents comprising the youth sample were aged

between 14 and 20 years old, with a median age of seventeen
years. The majority (61) were in school or college, ranging from
eighth grade in secondary school to the second year at colleges
and universities. The remaining 21 were either working or
searching for employment. The majority resided in urban and
suburban areas, about half resided together with their parents,
and although all were unmarried, five young women were
single mothers. The majority of the adolescent respondents
(65) reported themselves as sexually experienced–40 out of
52 females and 25 out of 30 males. Among the 61 currently in
school or college, 47 reported themselves as sexually active
(29 females and 18 males). Of the 21 who were working or
in search of work, 18 were sexually experienced (11 females
and 9 males).
The background and characteristics (sex, age, place of
birth, migration status, family income, religion, education,
school life, place of recreation, and friends) of sexually
experienced and inexperienced respondents were largely

similar, although the sexually experienced appeared
somewhat more likely to report that parents were separated,
divorced, or that one or both had died, and were more likely
to report use of legal (alcohol and cigarettes) and illegal
(amphetamines and marijuana) substances. Sexual health
problems, reported largely by the sexually-experienced group,
comprised, among females, missing periods, dysmenorrhea,
and vaginal bleeding following induced abortion, and among
males, dysuria (painful urination) and itching. None reported
the experience of sexually-transmitted infections despite the
fact that condoms were rarely used. Those who reported
contraceptive experience were most likely to report practicing
withdrawal; oral contraceptives were rarely mentioned.
A listing of providers in the 15 selected settings
suggested that unmarried youth tended to obtain services
largely from nurses and health educators. Hence the 44
participants included 16 nurses, 10 health educators, 7 doctors,
6 counselors, and 5 other health professionals (such as social
workers, program coordinators, and managers who ran
special programs for youths). Subjects ranged in age from 25
to 63 years old (with a median of 40). In general, staff of NGO
facilities tended to be younger than those of public health
facilities. Providers were overwhelmingly female; 33 out of
44, however, only one of the seven physicians was female.
Most respondents were well-educated, with a minimum of
a bachelor’s degree. About half worked in hospitals, and 30
worked in public health facilities.
Providers came into contact with unmarried youth in a

variety of settings, including family planning, gynecological,
and prenatal clinics, as well as delivery rooms, STD clinics,
health promotion, and other health centers. They also
provided services to young people in the course of outreach
programs conducted largely by NGOs in schools, workplaces,
and other community settings. Some were involved in
recently established, youth-friendly service settings including
the Youth Centers and Services, Friends’ Corners, and peer
outreach programs.
It was clear from the narratives of both young people and
providers that adolescents faced huge obstacles in acquiring
sexual health information and services, that these constraints
operated at couple, family and provider levels, and that as
a result of gender double standards, young females were
especially disadvantaged.
At the Partner Level: Power Imbalance in Sexual

Partnerships
Despite the persistence of traditional norms that stigmatize

sexual activity among unmarried females but condone it
among young males, there is considerable evidence of sexual
activity among young unmarried females. Opportunities for
interacting with males are plentiful, whether at school or in the
workplace. While young females are more likely than before to
enter into premarital sexual relationships, they remain poorly
equipped to prevent such outcomes of unsafe sexual activity
as unwanted pregnancy or infection. While some traditional
norms may have loosened, others have not. Hence, while

young females may be likely to engage in sexual activity,
gender double standards demand that they make every
effort not to disclose this, and that they continue to display,
even within the partnership, the desired characteristics of a
“decent” woman, namely passive and obedient behavior.
Double standards are evident, moreover, when motive
for engaging in sexual relations is considered. By and large,
young females tend to engage in sexual relations in order to
display love or cement a committed relationship. Young males,
in contrast, may also report this motive but are considerably
more likely to report such motives as a need to satisfy sexual
desire or simply curiosity. Interviews with female adolescents
clearly show that double standards and power relations
persist in sexual partnerships. Young women’s perceptions
of love involve, on the one hand, a wish to accede to the
boyfriend’s desire for sex, and on the other hand, fear that
reluctance to engage in sex or, indeed, revelation of problems
arising from sex would be met with indifference at best and
abandonment at worst.
Several young women reported that they agreed to
engage in sexual relations as an expression of their love
for their boyfriends and in order to strengthen what they
perceived as a committed relationship. At the same time, those
experiencing negative outcomes of unprotected premarital
sex rarely consulted or confided in their partners, in fear of
negative partner responses, including abandonment:
Girls usually talk to their friends when they have

sexual problems, especially pregnancy. They will not
tell their boyfriend because they are afraid that the
partner will not love them any more. Also, the boys
may have some doubts about who is the father and
then ignore the problem.1
Young females who had experienced an unwanted pregnancy

confirmed this lack of partner involvement:
When I got pregnant, I told my boyfriend and he

kept quiet. I asked him again a few days later and
he asked me what I was going to do. I told him that I
would get the baby out. I asked my friend who had
an experience before. She helped me to buy “inserting
tablets” [Cytotec].2
Young males themselves confirmed this impression and

described how they distanced themselves from partners
who became pregnant. Several absolved themselves of
responsibility arguing that a pregnancy, if it occurred, could
not be definitively attributed to them, as girls who engaged
in premarital sex were not “decent” women, and were prone
to promiscuity and multiple partners. Abandonment was
clearly one response:
One of my girlfriends got pregnant. She told me that I

was the father. I didn’t know what to do and wondered
whether I had been the only one who had had sex
with her. She wanted me to talk with her parents. I
1
Interview with 20-year-old female, 2001.
2
asked her for some time, so I could go looking for a

job in Bangkok. After I went there, I didn’t return to
her anymore. I know I was ashamed.3
Clearly, double standards pervade adolescent sexual

partnerships in ways that make young females particularly
vulnerable.
At the Family Level: Lack of Communication with

Parents on Sexual Matters
Thai society continues to be patriarchal and gender disparities

in socialization and sexual norms alike remain deeply
embedded in family life. Thai boys and girls are brought
up and disciplined under different sets of rules and double
standards in role expectations and appropriate conduct are
imparted from an early age. While widespread access to
formal education has narrowed gender inequity in some
respects, norms about premarital sexual activity among
females and males remain strong.
Interviews with 82 adolescents in our study provided
considerable evidence that double standards with regard
to sexual morality and practice remain strongly accepted in
Thai families. Young men were not only allowed but also
encouraged to experiment with sex before marriage –indeed,
such an activity was considered a rite of passage for teenage
males. Sex was one of issues that father and son, or male
teacher and male student, could discuss reasonably openly:
3
Interview with 20-year-old male, 2001.
When I have sexual problems, I consult my dad. He told

me that he lost his virginity when he was in the second
year at college. He told me, “Just use a condom,” but
sometimes I don’t.4
The teacher in school taught me how to use a condom.

It was in our health education class. It was so funny
and we all laughed. He gave us information and
demonstrated by using a model. However, I have not
yet had the experience to use it outside the class.5
Similar openness was rarely expressed by young females. On

the contrary, their narratives confirmed that open discussion
of sex or condoms was considered inappropriate for young
women and that they were expected to preserve their
innocence and virginity until after marriage. Any deviation
from this norm was considered detrimental to the reputation
of their parents, their families and perhaps even their marriage
prospects. Sexual matters were not commonly discussed
between girls and their parents, for fear that such discussions
might lead young girls to experiment with sex.
I told my mum when I had irregular menstrual periods.

She wanted to take me to the hospital. I told her that I
didn’t want to go and that I was afraid, because I had
never [had sexual experience] before. But I actually
feared that the doctor would do a vaginal examination
4
5
on me [and reveal sexually-active status]. She didn’t

know I had sex and she will never know.6
Despite the advent of the HIV/AIDS epidemic and the

recognition of the importance of safe sex practices, adolescents
in our sample revealed that some parents continued to
oppose the attendance of their daughters at sex education
programs provided by NGOs, fearing that these programs
would encourage sexual experimentation among them. Some
teachers, moreover, reportedly refused to allow sex education
activities in their schools, believing that their students were
unlikely to need such education.
These inhibitions at parental and school level further
enhanced the vulnerability of female adolescents. Not only
did they lack knowledge of safe sex practices, but also the
means to ensure safe sex practices. If confronted by unwanted
pregnancy or infection, they feared consulting parents,
providers or other trusted adults and having to reveal their
loss of virginity. Many reported that parents would be the
last resource they sought in case of unwanted pregnancy or
infection. Indeed, several adolescents reported that they had
never informed their parents of these adverse outcomes:
. . . and then I did it [induced abortion] by myself

at home. My mum was there but she did not know
anything. I told her that I had headache and spent two
whole days in my bedroom.7
6
7
After I asked someone [a woman who helped girls

wanting induced abortion] to put the “inserting
tablets” into vagina, I went back home, and waited
for one or two days to get the baby out. I just stayed
in my bedroom and then I got cramps and bleeding.
I went to the bathroom around ten times. My parents
were aware of this and asked me what was going on.
I told them I had diarrhea and they gave me medicine.
I didn’t take it but told them that I had. I was almost
dead at that time.8
Findings clearly suggest the persistence of double standards

and sexual norms that continue to stigmatize premarital
sex for females while condoning it for males, and continue
to power relations that inhibit the exercise of safe choices
by young females. They underscore the extent to which
these factors place sexually-active adolescent females in a
particularly vulnerable position, unable to seek help from
parents or to rely on partners.
At the Provider Level: Unfriendly Care and

Judgmental Attitudes
Programs and services for adolescent sexual or reproductive

health were implemented by both public sector facilities and
non-governmental organizations. Collectively, providers
reported a range of services sought by unmarried youth,
both in clinic settings and in outreach programs. Services
8
included physical examinations and treatment of menstrual

problems (e.g., cramps, missed periods, vaginal bleeding),
provision of family planning information and contraceptives,
prenatal care and assistance at delivery (providers observed
that adolescent pregnancy appeared to have increased and
reported clients aged as young as 13 to 14 years old who had
to leave school because of pregnancy), and post-abortion
care (e.g., uterine curettage, the removal of growths or other
material from the wall of the uterus. Nurses at the Maternal
and Child Hospital reported that around 70 percent of females
experiencing vaginal bleeding after an unsafe (illegal) abortion
were students under 20 years old, that HIV testing and STD
treatment as given mostly to male teenagers and to young
female sex workers (among whom testing is mandatory), and
that information and counseling were provided during the
course of visits for other services or through such dedicated
mechanisms as telephone counseling and special programs,
e.g., Chiang Mai Youth Counseling Programs, Youth Centers
and Services, and Friends’ Corner, mainly operated by
NGOs.
Public sector facilities were perceived to be very
threatening by adolescents, particularly by young females.
Providers acknowledged that young clients were comprised,
disproportionately, of young males and female sex workers.
Indeed, few adolescent females attended these facilities.
The usual clients using the services here are sex

workers. However, male clients do not mind coming
here. Some male teenagers come to see us. The main

problems are dysuria and gonorrhea. For young girls,
if they are not sex workers, they do not come here.9
Interviews with providers suggested that providers were

not sensitized in addressing adolescent sexual needs. They
tended to be impatient, held judgmental attitudes and had
reservations about serving unmarried youth, particularly
females. Ambivalence about preserving young people’s
confidentiality was also evident and young people reported
difficulty in developing rapport with providers. Adolescents
tended to be perceived as problem-makers rather than as
vulnerable clients in need of care. In many government
facilities, young clients were required to identify themselves
and provide personal details in order to obtain services,
a requirement that was quite impractical for adolescents
seeking sexual health care. Provider attitudes were evident
from the following:
Some girls did not want to tell us the truth. They had
vaginal bleeding and told us that they had an accident.
But when we did examinations, we found the pieces
of Cytotec left in the vaginal canal.10
Some girls called me at the clinic and asked about

how to use drugs to terminate pregnancy. They told
me that they would present this topic in class or write
a report. I advised them to get a formal letter from
9
Interview with 41-year-old male STD clinic doctor, 2001.
10
Interview with 37-year-old male hospital doctor, 2001.
their school and send it to the clinic, and then I would

give them details. None of them did this; they just
disappeared.11
When we gave them the information, they didn’t

respond at all. They kept quiet and didn’t react at all. So
we couldn’t know whether they had understood what
we had tried to explain. We have so much work to do
in the clinic that sometimes it makes us annoyed when
dealing with them. A staff member in the labor room
complained that some girls would jump out of the bed
when she did the PV [vaginal exam] on them.12
Many providers were often unwilling to take the responsibility

of providing services to these young women, and, moreover,
viewed their inability to pay for services as a financial burden
for the institution.
The problems we always face are that the girls come

to the hospital with friends. The parents do not know
about their daughters’ problems. After the treatment,
which usually ends up with uterine curettage and a
set of antibiotics, the girls don’t have enough money
to pay. Some of them live in flats or rented house and
get some help from friends, not from partners.13
Interviews with adolescents suggested that although

providers displayed threatening attitudes when serving
11
Interview with 40-year-old female hospital nurse, 2001.
12
Interview with 37-year-old female hospital nurse, 2001.
13
Interview with 56-year-old female public hospital nurse, 2001.
unmarried youth in general, young females were much more

likely to face judgmental provider attitudes than were young
males. As indicated below, the negative consequences of
unsafe sex among males appeared to be tolerated:
Once I had a problem, so I went to see a doctor at a

clinic. I definitely chose a male doctor because I had
itching and dysuria. The doctor blamed me at first and
I kept quiet. Then, he talked to me nicely and taught
me how to use a condom. He told me to be careful
when I slept with girls. He told me to be aware of
AIDS too.14
In contrast, young females feared provider attitudes that

labeled sexually-active females as “promiscuous” or “bad
girls” and that appeared unwilling to provide sensitive
counseling and care to them:
I’m too shy to go to the clinic. I’m not even 15 years

old. They must think of me as a bad girl, having sex
very early. I’m afraid of their reactions and the words
that I would receive. So I always ask my friend to buy
drugs [some herbs for inducing menstrual period] at
the drugstores.15
The nurse in the hospital was not so nice. I once went to

a hospital because of missing my period. A pregnancy
test turned out positive. I was not ready to have a baby
14
15
and didn’t know what to do. I asked for some help

from a hospital staff member but she didn’t give me
any advice other than telling me to keep the baby. I
told her that I was a student and I wanted to finish my
school. She said I deserved it [pregnancy] and that I
needed to take responsibility. I was so angry, I almost
punched her face. So I went back, told my mum, and
had a self-abortion by using “inserting tablets.”16
I need someone to talk to me nicely. When my friend

went to the hospital to get a vaginal exam, she was
scared. The nurse yelled at her and the hospital staff
was not very nice although we paid for the service.
They asked us, “Why didn’t you think before sleeping
with somebody?” That hurt.17
Clearly the experiences and perceptions of adolescents

corresponded with the attitudes and statements expressed
by providers. It is no surprise then that sexually-active
adolescent females preferred to seek care in other ways–self-
treatment, the advice of friends or drugstores that were more
impersonal, less judgmental, and sometimes less effective:
I can talk to my group of my close friends. We all have

sexual experience and we accept each other. I always
tell them about my partners, or sometimes when I’m
having menstrual problems. We help each other when
one of us has any problems.18
16
17
18
I had clot bleeding after missing my period for two

months. I didn’t take any medication but just kept
pressing my stomach, then I had severe cramps. I
went to the bathroom and saw a lot of blood flowing
from my vagina. I asked my friend about what was
going on. She didn’t know either, but she stayed with
me and helped take care of me. She brought me some
drugs to relieve the pain. I didn’t go to a hospital
because I was too embarrassed. After a few days, the
bleeding became just like a normal period. I am not
sure whether that was an abortion or not.19
My girlfriend used to miss some periods from time

to time. I was the one who bought her the drugs for
inducing a period. I went to a drugstore and asked
for medication. The seller asked me, “How many
months” [of missing period]?” I told him and paid
for the drugs. It was so easy. Later, the drugs were not
working well. My girlfriend still got pregnant. She had
to go to a private hospital [illegally] for an induced
abortion. I didn’t go with her and didn’t talk about it
[the abortion] after that. Now we are still seeing each
other.20
By and large, providers at NGO facilities were more likely

to offer acceptable services for young females. Innovative
programs they provided were described as adolescent-
friendly and allowed confidentiality and even anonymity.
19
20
Examples included telephone counseling, Friends’ Corner,

Peer Outreach Program, and Baan Ping Jai (emergency services
for young girls in crisis), which aimed to attract young people,
especially girls. Peer counselors and young staff were often
employed in NGO facilities. NGO facility providers described
the success of such programs:
Adolescents using the service here are mainly girls.

Many start to have sex when they are in grade seven
or eight. Most of them don’t use any protection.
The girls are persuaded to come here by our young
staff. The young volunteers do their work very well.
Anyway, our job here is only for counseling and health
education. We don’t give any treatment. We have
to refer those cases to the hospital where we have
connections with the doctors.21
We give small incentives to the young volunteers. They

help us giving health education and selling condoms
and pills to their friends. We monitor the program by
having monthly meetings with them. They show us
their work outcomes and we discuss the problems
they face. Sometimes we invite their clients to join us,
to discuss how to provide services which are more
acceptable.22
There were, however, exceptions among the providers at

government facilities, several of whom recognized the need
21
Interview with 46-year-old male NGO counselor, 2001.
22
Interview with 28-year-old NGO program manager, 2001.
to make clinics and other facilities more youth-friendly. These

providers argued for the provision of services at locations and
timings convenient for young people, with less threatening
and less judgmental provider attitudes. They recommended
that services be integrated and complemented by outreach
programs. They argued for the participation of youth in the
design and management of services for young people. They
also emphasized the need to re-orient providers, facilities,
and government reporting systems to accommodate young
people’s need for confidential services:
What is needed now is to change our attitudes toward

sexuality when we give services to young people.
We need to see sexuality as a step of adaptation from
childhood to adulthood. At this point, we should give
them services in a positive atmosphere. Adolescents
need to feel secure, comfortable and ensured of
confidentiality. If we can do this, I believe it would
help.23
It’s time to think about setting up a clinic for

adolescents, especially young girls, to do check-ups,
screening, and treatment focusing specifically on
sexual and reproductive health. They will come to
use the service if we set up a clinic the way they want
it.24
23
Interview with 43-year-old male hospital doctor, 2001.
24
Interview with 38-year-old male health center counselor, 2001.
Discussion and Conclusion
This paper has explored the perspectives and experiences

of a range of providers and adolescents themselves and has
highlighted the kinds of gender double standards and power
imbalances that confront sexually-active adolescents. It has
highlighted the extreme vulnerability of sexually-active
adolescent females. Indeed, adolescent females experiencing
unwanted pregnancy or problems arising from sexual activity
often faced indifference or the threat of abandonment by their
partners. Sexually-active adolescents so feared disclosure of
their sexually-active status to their parents and communities
that they opted for clandestine and unsafe abortion and sought
the counsel of peers and drugstores rather than parents and
providers. Finally, at the provider level, adolescent females–far
more than males–faced threatening and judgmental provider
attitudes, indifferent counseling, and possible violation of
confidentiality. Providers from government settings expressed
some unwillingness to accommodate the additional time
requirements of young women who sought counseling or
other services, as well as some frustration about young
females’ unwillingness to reveal their sexual histories and
follow up on prescribed treatment.
This paper reveals a lack of understanding of the
difficulties young female clients encounter in expressing their
needs and admitting their sexually-active status, and the range
of fears they may have, whether of violation of confidentiality
or inability to pay for needed services.
Findings call for interventions at several levels. They

argue for programs that build life skills among adolescents.
More specifically, programs are needed that sensitize young
males to take responsibilities in ensuring safe sex in their
partnerships and to support partners who may experience
adverse outcomes of risky sex. Equally, programs are needed
that enable young females to make sexual and reproductive
decisions and exercise informed choices in their sexual
lives.
Parents and communities also deserve attention. We have
seen that parents practice traditional gender double standards
in the ways in which their children are socialized and that,
as a result of norms that stigmatize sexual activity among
unmarried females, adolescent girls are unlikely to seek the
support or assistance of their parents in addressing sexual
health problems. Parents are unwilling in several instances
to agree to the provision of sex education to their adolescent
daughters, while at the same time being reluctant to discuss
these matters with them directly. What is required, then, are
programs addressed to parents that sensitize them to the risks
that young people, including young females, may face and
support them in overcoming reluctance to communicate on
these issues with their children, and particularly with their
daughters.
Additionally, findings here suggest, as other studies have,
the need for training and sensitizing of providers who serve
unmarried youth, especially young females. This requires
more stringent recruitment practices that ensure that those
providing services to unmarried young females do indeed
have positive attitudes and necessary skills to build rapport

with young clients. Also, as other studies have suggested,
facilities offering services to youth need to be reoriented to
be more inviting to young female clients. While convenient
timings, privacy in waiting areas and consulting rooms and
easier admission procedures are some ways of accomplishing
this, it is vital that young people themselves are involved in
designing and monitoring the youth-friendliness of clinics.
Special youth-friendly initiatives that have been launched
offer promising directions for serving young females, but their
sustainability and potential for improvement suggest that
efforts need to be made to incorporate their central features
into established facilities.
Finally, it is essential that policy and program-level
ambiguities are addressed, that providers are given clear
guidelines on services for unmarried youth, and that reporting
requirements are streamlined to accommodate young people’s
needs, with more attention paid to gender issues.
Acknowledgement:
This study received financial support from the UNDP/UNFPA/WHO/World Bank
Special Programme of Research, Development, and Research Training in Human
Reproduction, World Health Organization, Geneva. The authors are grateful to
Drs. Iqbal Shah and Shireen Jejeebhoy for their comments and suggestions.
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✤✤✤
Sexual Behavior
of Young
Out-of-School
Males in
an Indonesian
Urban Slum
Sexual Behavior of Young
Out-of-School Males in an
Indonesian Urban Slum
Laurike Moeliono
Introduction
In Indonesia, available case studies suggest that 5 to 10 percent

of young unmarried females (15 to 24 years old) and 20 to 30
percent of unmarried, young males (15 to 24 years old) have
engaged in sexual activity (Khisbiyah & Murdiyana, 1996, pp.
4, 35; Sapruddin, 1999, p. 25; Singarimbun, 1991; Situmorang,
2001, p. 144; Sumiarni, Wardhada, & Abrar, 1999, p. 3). Much
of this activity is risky. Estimates suggest that approximately
half of all those infected with HIV are aged 15 to 24 years, and
about one-third of all abortions conducted annually occur to
women aged 15 to 24 years.
While the sexual health needs of all young people
remain poorly known and served, those of marginalized sub-
populations of youth residing in the slum areas of metropolitan
cities remain especially neglected. This is despite the concern
that risky sexual activity is particularly prevalent among the
youth residing in these settings (Moeliono, Anggal, & Piercy,
2001, pp. 47-55). The objective of this paper is to shed light
on one such marginalized group–young males residing in
a Jakarta slum, the majority of whom are out of school and

face limited economic opportunities. In particular, the paper
details the sexual behavior patterns and risks faced by this
group of young people. It reports findings from a qualitative
case study which may be used to inform the development of
programs and interventions for marginalized young males
in Indonesia.
Background
Within Indonesia’s population of 220 million in 2002,

approximately 44 million or 20 percent are aged 15 to 24
years. Of the population aged 7 to 24 years, approximately 38
percent live in urban areas and half of these reside in the peri-
urban slums of major metropolitan cities (Biro Pusat Statistik,
2000b). Education and economic activity data suggests that
large numbers of these young people are neither in school
nor working.
At the national level, 92 percent of those aged 6 to 12
years old attend primary school, 59 percent of those aged 12
to 15 attend secondary school, and 38 percent of those aged
15 to 18 attend high school (Biro Pusat Statistik, 2000b). As
such, about half of all young people are no longer in school by
age 13 and about three in five are out of school by age 15. In
general, poverty and, in the case of females, early marriages
are leading reasons for early school dropout (Biro Pusat
Statistik, 2000b). At the same time, employment opportunities
are scarce for out-of-school youth in urban slums. Only 29
percent of youths aged 15 to 19 and 56 percent of those aged
Sexual Behavior of Young Out-of-School Males in an Indonesian Urban Slum
20 to 24 were reported to be economically active, including

working on the streets and in domestic service (Biro Pusat
Statistik, 2000b)
Although national-level data is limited, evidence from
small studies in selected urban areas suggests that premarital
sexual activity is not unknown among young people in
Indonesia (Khisbiyah & Murdiyana, 1996, p. 35; Sapruddin,
1999, p. 25; Singarimbun, 1991; Situmorang, 2001, p. 144;
Sumiarni, Wardhada, & Abrar, 1999, p. 3). For example, the
Indonesia Demographic Health Survey finds that 6 percent of
young married women aged 20 to 24 report premarital sexual
activity (Biro Pusat Statistik, 1997). Similarly, findings from a
study of about 3,600 unmarried young people in 12 large cities
in Indonesia indicate that between 5 to 30 percent are sexually
experienced (Hatmadji & Rochani, 1993, pp. 1, 24). A third
study, of 875 young people aged 15 to 24 years in the city of
Medan, Sumatra, finds that 27 percent of males and 9 percent
of females had engaged in premarital sex (Situmorang, 2001,
p. 144). There is, moreover, evidence that much of this sexual
activity is unsafe. Estimates suggest that about half of all those
infected with HIV are aged 15 to 24 , that those residing in
Jakarta are most likely to be at risk (Departemen Kesehatan,
2001) and that about one-third of all abortions conducted
annually occur to women aged 15 to 24 years (Khisbiyah &
Murdiyana, 1996, p. 43; Utomo et al., 2001).
Despite this, reproductive health information and services
remain limited for unmarried youth. For example, a recent
study conducted in West Java among 1,189 rural and urban
youth suggests that 60 percent remained poorly informed
of sexual health issues, including unwanted pregnancy and

its risks. The study further highlighted the reluctance of
parents and schoolteachers to convey information to youth
on reproductive health issues (Departemen Kesehatan,
1995-96). This reluctance is reinforced by norms, morals,
and religious values that in practice restrict young people’s
access to contraceptive and reproductive health services
unless they are married. Insurmountable obstacles inhibit
unmarried youth from acquiring services, counseling or even
public education related to family planning, safe abortion,
or sexually transmitted infection (STI) treatment (Djaelani,
1996, pp. 307-316; Situmorang, 2001, p. 147). As a result, youth
tend to develop their own–sometimes risky–mechanisms for
addressing sexual and reproductive health needs.
Young people residing in urban slums are particularly
disadvantaged. They are more likely than others to be out
of school and less likely to be engaged in economic activity.
Housing conditions are modest and cramped, allowing little
privacy. Typically, young people, particularly males, are
observed to be “doing nothing”–socializing with peers at street
corners and outside teashops located within the slum. Perhaps
as a result of these conditions, risky behaviors, including
substance use and unprotected sex, are not unknown among
young people in these settings, including Duri Utara, a typical
peri-urban slum of Jakarta and the locale for this study.
Setting
Duri Utara, located in the western part of Jakarta, is one

of Jakarta’s most densely populated peri-urban slums. It
has a population of 26,862 and covers some 20 hectares
with 8 districts that further divide into 14 sub-districts.
The population density is about 14,000 people per hectare.
Housing is cramped and structures are semi-permanent,
offering residents little privacy, light, or air. Most homes have
electricity, but water and toilet facilities are shared and open
drains run along the rows of homes. Escaping from these
cramped quarters, young people, particularly young males,
tend to assemble in tongkrongan, selected locations along the
lanes of the slum that provide a meeting place for networks
of young males.
Like those in other slum areas, residents of Duri do have
access to public health services in the vicinity (Community
Health Services) as well as to private clinics. While these
facilities do provide reproductive health services, such
services are available, in practice, only to the married. As in
the rest of Indonesia, young people in Duri face huge obstacles
in gaining access to accurate information or services for their
sexual and reproductive health needs.
Methodology
Data is drawn from an entirely qualitative study of young

people in Duri aged 15 to 24. The study was designed to
be participatory, with selected local youth forming the
research team. In a first step, investigators mapped locations

where young people congregated or “hung out.” Through
discussions, youth leaders were identified and selected
for the research team of the study. Peer researchers were
trained extensively in research methods and interviewing
techniques.
Several phases of investigation were conducted, including
participant observation and a narrative exercise with 40 young
males, 6 focus group discussions (FGDs) involving 48 young
males residing in different parts of the slum and engaged in
different activities (full or part-time work) or unemployed,
and in-depth interviews with 6 young males as well as 14 best
friends or partners, 3 parents, a community leader, a drugstore
keeper, and 2 midwives. The narrative exercise and FGDs
were held with the following groups of young males: (a) the
unemployed, including one group of unemployed drug-users;
and (b) those with part-time or temporary employment.
While the original intention was to conduct this study
among both young males and females, we were not able to
recruit a sufficient number of females, and hence this paper
is restricted to the perspectives of males. Study participants
were selected purposively, with the goal of exploring norms
and practices.
A Profile of Young Males
A mapping of the community suggests that youths aged 15

to 24 comprise 20 percent of the population and number
about 5000. The majority have some secondary or high school
education but about 15 percent are less educated. Because

the majority of young males are out of school, economic
opportunities are limited and the majority of these young
males are unemployed. Some, however, do have part-time or
temporary employment as factory or construction workers,
painters, machine operators, parking lot attendants, or
employees in restaurants and gambling stalls.
Since a large majority of young males are not engaged
in either schooling or work, these young men may often be
observed socializing in groups in public places such as malls,
street corners, alleyways, and outside shops or mosques. The
home, in contrast, is ,perceived as a place to eat and sleep but
not to engage in social interaction. Sites where young males do
interact socially are known as tongkrongan (loosely translated
as, “places to hang out”).
What we [youth] do everyday is usually “nongkrong”–

chatting, sometimes playing station or videogames . . .
When we come together, we talk about daily activities
. . . sometimes we talk about our private problems
. . . about relationships.1
Tongkrongan tend to be loosely structured meeting places with

neither formal leaders nor fixed-group membership. Although
they tend to be open to all young people to nongkrong, in
practice, a young male will tend to associate himself with
a particular tongkrongan. Tongkrongan are selected for their
1
FGD, temporarily-employed group, 5 September 2000.
geographic convenience (near home, near working activity,

in the same sub-district as one’s residence, or in a better area)
or for the peer network frequenting it (friends with similar
characteristics and interests). Tongkrongan activity typically
occurs until late at night.
Tongkrongan offer young males their main source
of information, counseling, and support with regard to
friendship, girls, and dating, as well as sexual and reproductive
health matters. “We can exchange ideas about each others’
problems,” reports one temporarily employed male.2 Young
males report that the tongkrongan enables them an opportunity
to discuss intimate concerns that they are inhibited from
raising with their parents. As expected, however, this forum
has both positive and negative influences. On the positive
side, tongkrongan are a source of information, support, and
peer counsel: “When we feel bad . . . we can get support from
friends we meet at the tongkrongan,” says one unemployed
male.3
On the negative side, this peer network serves to
perpetuate sexual misperceptions and strengthens peer
pressure for risky sexual and other behaviors. Young males
describe a host of risky behaviors that they associate with
their participation in these networks–risky sex and sex worker
contacts, reading and watching pornographic materials, drug
use, and gambling. “Usually, we do not have any plan [to
go to the brothels], only when we meet at the tongkrongan,”
explains one such male.4 Pressures to conform to high-risk
2
3
FGS, unemployed group, 5 September 2000.
4
Interview, temporarily-employed, 24-year-old male, October 2000.
group activities are repeatedly reported by young males in

the area. For example, one young male states, “If we don’t do
drugs, like our friends at the tongkrongan we feel uneasy, so
we do it too.”5 Thus tongkrongan, while a source of support
to marginalized slum youth, may also be a leading factor
influencing youth toward risky sexual experiences.
Parents don’t care about their children, for example

myself–my parents work and I don’t get enough
attention. To lessen the boredom, I usually go
nongkrong, to socialize . . . it gives us freedom–freedom
to be drunk, to have sex with girls . . . nobody cares
. . . I don’t care. What’s important for me is to be
accepted by my friends . . . because with friends we
can exchange ideas.6
Risky Sexual Experiences
It is evident from the narratives, FGDs and in-depth

interviews that large proportions of young males residing in
Duri are sexually experienced. Although they acknowledge
the persistence of traditional norms prohibiting premarital
sexual relations, only a small proportion of males–and a larger
proportion of females–are said to adhere to these social and
religious restrictions on behavior. Rather, discussions with
young males reveal a wide perception of changing norms
and widespread sexual activity. Premarital sex is consistently
reported to be quite “common” and “taken for granted.”
5
FGD, temporarily employed group, 5 September 2000.
6
Interview, temporarily employed, 19-year-old, October 2000.
Indeed, as the following examples suggest, premarital sex

has become part of the youth subculture in this setting. As
one young male stated, “Ninety percent of the youth [boys]
in Jakarta are not “pure” [virgin] anymore...but of course it
depends on the person.”7
Interestingly, several parents appear to be aware of the
premarital sexual activity of young people and although they
disapprove, they recognize that they have little authority to
prevent it. One mother reports, “It’s the era, it’s common
among young people [to have premarital sex], it‘s already a
tradition among the youth . . . ”8 Indeed, young males report
that sexual activity is most likely to take place in their own
homes in the absence of parents. The mother quoted above,
perhaps an extreme case, suggests that sexual activity even
took place in the home when parents were present: “She
[girlfriend of the son] often comes here and gets into his room
. . . but what can I say?”9
Partners are drawn from both within and outside the
neighborhood. Dating is said to include both non-penetrative
and penetrative activities and young males report strategies
used to pressure young females to engage in sex:
Yes, there are boys who take the chance with girls
who are in love with them. The boy asks [pressures]
the girl to have sex, as a proof of love. There are girls
who, because of love, are willing to do that.10
7
FGD, unemployed, drug user group, 5 September 2000.
8
Interview, mother of an unemployed 22-year-old male, October 2000.
9
Interview, mother of an unemployed 22-year-old male, October 2000.
10
Interview, unemployed, 23-year-old male, October 2000.
Data also suggests that premarital sexual experiences are

largely unsafe. Multiple partners, sex worker contacts, and
non or irregular use of condoms are frequently reported. One
male boasts about his multiple sex partners, “I can do it with
my own girlfriend, but also with another [secret lover].”11
Young males make a clear distinction between sexual
relations with a steady partner and with a casual one.
Premarital sex is used to refer to sex with a steady partner, one
with whom marriage may be considered. On the other hand,
“free sex” is the term used to describe sexual relations with
casual partners (male or female) and particularly with sex
workers and call girls. Young males identify two types of paid
sex partners: commercial sex workers and dongdot, or call girls.
Commercial sex workers are described as older women, forced
to accept any client, brothel-based, and charging “standard”
prices. In contrast, dongdot are described as younger, able to
refuse clients and usually preferring “young and attractive
men.” Moreover, dongdot are not necessarily brothel-based,
often conducting their business in small hotels in the area;
they are also considerably more expensive than commercial
sex workers. For this reason, youth express a preference for
brothel-based sexual activity.
Sexual relations with sex workers are frequently
reported and are often described as a group activity, usually
spontaneous and largely dependent on the availability of
cash.
The extent to which young males engage in sexual
relations with sex workers depends to a considerable extent
11
on the availability of resources. There is a consensus that sex

workers in the brothels most often frequented by young males
from Duri, located in Kalijodo and Muara Angke, charge
between Rupiah 30-50,000 (equivalent to US$35 in 2000).
This is an exorbitant sum for the average young male who, if
employed, earns no more than Rp. 25,000 (US$2.50) per day.
Earnings from gambling are also used to support relations
with sex workers. “We go to the brothel almost once a week
and ‘buy sex’ . . . because we earn the money from gambling,”
says one young male.12
Masturbation is perceived as an alternative to “free sex”
if resources are unavailable or for those who believe that
contact with sex workers is sinful. One male explains: “After
watching [pornographic] VCDs, we go to the bathroom and do
‘hallo-halo bandung’ [a term for masturbation] . . . there are also
friends who go to the brothels.”13 The topic of masturbation
was raised frequently in all FGDs, interviews and narratives.
It was referred to as a normal and common activity among
young males and one that they were not ashamed to discuss
among peers in the tongkrongan.
Despite evidence of quite widespread risky sexual
activity, condom use is negligible. Few young males report use
of condoms and even fewer report regular use: “No condom,
boys don’t use condoms . . . if you use condom, it’s not sex.
Sex is skin to skin. With protection it’s not pleasant.”14
12
Interview, 24-year-old male, October 2000.
13
14
Interview, 24-year-old male, October 2000.
There is, moreover, limited awareness of the protection

provided by condom use, also misconceptions and myths
abound concerning safe-sex behaviors. For example:
To prevent pregnancy, girls take pills . . . capsule-M

[pill for menstrual regulation] with Sprite [soda water]
. . . If girls forget to take the pill, they have to squat
afterwards. Another way to prevent [pregnancy] is
peeing afterwards because at that time the sperm
hasn’t got in so it can flow out with the pee . . .15
After having sex I always drink jamu’[herbs] or other

obat kuat [pills], which can make me strong . . . just as
prevention from diseases . . . 16
Finally, while young males report traditionally negative

attitudes concerning the use of condoms, they also reveal a
sense of invulnerability to infection: “I don’t use protection...
I have no thoughts about disease.”17
In summary, the evidence suggests that risky sexual
behavior is widespread among marginalized slum youth in
Duri. Sex worker contacts are well known and condoms are
rarely used. Peer networks are important in reinforcing and
supporting risky behaviors and several reported peer group
activities set the stage for risky behaviors.
15
16
17
Setting the Stage for Risky Sexual Behavior
Young males report a number of activities that set the stage

for sexual relations, particularly “free sex” relations. These
include peeping into the homes of neighbors engaging in
sexual relations, watching pornographic films, and using
alcohol and drugs. By and large, these are described as
group activities conducted by two or more members of a
tongkrongan.
Peeping or observing couples having sex in their own
homes is considered entertainment and is easily available,
given the lack of privacy as a result of crowded living
conditions and open structures typical of Duri. Indeed,
young males describe how prospective couples–for example,
those recently married–are identified and peeped upon by
tongkrongan members as a precursor to sex: “There is an open
opportunity . . . so everyday I peep . . . so we get sexual desire
. . . the way out is to masturbate . . . or better, to have sex.”18
Aside from peeping, sexual desire is also aroused
by watching pornographic films. Young males report
that sexual activity–both with girlfriends and especially
with sex workers–is often preceded by group viewing of
pornographic films. “It starts with watching [pornographic]
VCDs . . . We become aroused . . . What is seen in the video,
is practiced.”19
Drug and alcohol abuse is widely reported in the
narratives, discussions, and interviews. Young males estimate
18
19
that about half of the young males in Duri had experimented

with or were currently using drugs. One male states, “The
most popular activity among youth in Duri is taking drugs.”20
Substance use is a group activity within the tongkrongan, and
the peer pressure to engage in substance use is difficult to
resist.
Influence of peers . . . if we do not use, they will say .
. . You are like a girl, like a transvestite’...
I didn’t feel comfortable when I got together with
them [peers] but didn’t use [drugs] . . . To respect them
[peers], finally I also use them [drugs].21
While substance use is widely associated with peer pressure,

it is also recognized as setting the stage for sexual relations.
Young males repeatedly report the link of drugs to sexual
desire and relations. Many study participants report using
drugs prior to having sex with both girlfriends and sex
workers:
Buy drugs . . . use drugs and immediately my sexual
desire is aroused . . . then I use the girl . . . everybody
here has used her [referring to a sexually active girl in
the area].22
After using ‘shabu’ [methamphetamine], I lose controI

. . . don’t think about disease . . . the only thing I want
to do is have sex.23
20
21
FGD, unemployed group, 5 September 2000.
22
FGD, temporarily-employed group (mostly parking lot attendants), 5 September 2000.
23
Interview, unemployed, 23-year-old male, October 2000.
As a group activity, drug use includes sharing needles

especially heroin–described by one male as, “the needle . . . we
use together . . . “ Although risks relating to sharing of needles
are not particularly well understood, young males appear to
associate several mental and physical disorders and deaths
of young people in the neighborhood with drug use:
Already three of our friends [in one district] died . .

. In a couple of years, four friends died . . . usually
[because of] PT24 [heroin] . . . they were friends who
usually hung around with us.25
In summary, peer networks expose young, marginalized

males to activities, such as peeping and substance use, that
set the stage for risky sexual relations. At the same time,
these peer networks also enable them to engage in these risky
sexual relations, such as with sex worker partners. These peer
networks also transmit messages that associate masculinity
with such risky behaviors as drug use and non-use of
condoms. Such consequences as infection and unwanted
pregnancy are not unknown.
Outcomes of Risky Sexual Activity
Study participants are not unfamiliar with the adverse

consequences of risky sexual relations. One male acknowledges
the experience of symptoms and expresses a fear of HIV:
24
PT stands for Putaw, which is local Indonesian slang for heroin.
25
“. . . I think I get a disaster...do I have AIDS?”26 By and large,

symptoms of sexually transmitted infection are a source of
pride, masculinity, a sign of prowess and also perceived as
inevitable. “I go to the brothel . . . if we get a disease . . . it’s
fate . . . I have thought about it but never got it,” states one
male.27 As a source of pride, sexually transmitted infections are
openly discussed in peer networks. Indeed, it is this network
through which young males learn of the experiences of their
peers and obtain information concerning seeking treatment.
One male describes the experience of his friend:
That night [after visiting a brothel], when he wanted

to pee, his penis hurt very badly . . . He went to the
doctor and the doctor said, “You like to go to the
brothel, don’t you?”28
Making a girl pregnant, similarly, is not always perceived

as a negative outcome. Rather, sometimes it is perceived as
a strategy to force a boy’s parents to consent to the marriage
of their young son. Similarly, young males report convincing
or coercing their girlfriends to become pregnant so that the
girls’ parents are forced to accept the relationship and they
can get married.
I want my girl to be pregnant, to prove . . . you know

my parents don’t care . . . If I hadn’t done this [having
sex and making my girlfriend pregnant], my parents
wouldn’t see [care].29
26
FGD, temporarily-employed (mostly parking lot attendants), 5 September 2000.
27
28
FGD, temporarily-employed group (mostly parking lot attendants), 5 September 2000.
29
There are many youth here who just do it [have sex]

because parents don’t agree with the relationship.30
Many [unwanted pregnancies] happen here and not

only in Duri. It happens because of the parent factor.
Because parents don’t permit it, they just do it.31
Interviews with parents reinforce this perception. For example,

one mother states, “If my daughter becomes pregnant, the
only way is to be responsible, they must be married . . . ”32
On the other hand, if a girl becomes pregnant and
marriage is not an option, the pregnancy is perceived as an
unfortunate event that is easily remediable through abortion:
“Of those who become pregnant, there are those who get
married and there are those who have abortions,” says a
young male.33
Clearly, findings suggest that young males necessarily
perceive neither infection nor pregnancy as adverse
consequences of sexual relations.
Conclusions and Recommendations
The findings of this case study highlight the extreme

vulnerability of marginalized urban youth in Jakarta. Poorly-
educated, with few employment opportunities and residing
30
31
32
Interview, mother of 16-year-old female, October 2000.
33
in semi-permanent structures with little privacy, young

males turn to peer networks and tongkrongan for support,
information, and counseling. While peer networks do indeed
play a positive role in these respects, their influence is not
entirely positive and risky sexual and related behaviors are
observed to be reinforced by peer group networks. Young
males report drug use, peeping, and accessing pornographic
materials as setting the stage for sexual activity. They also
report such activities as gambling and stealing to obtain the
money necessary to engage in “free sex.” From discussions,
it appears that these behaviors are perceived as substitutes
for lack of work and other legitimate opportunities for young
people.
According to the data, risky sexual behaviors are not
uncommon. While committed relationships with females in
the neighborhood are reported, young males engage in “free
sex” with casual partners, rarely use condoms and remain
poorly informed about safe sex practices. Finally, infection
and pregnancy are not necessarily perceived as negative
outcomes of sexual relations, but rather, are seen as events
reinforcing masculinity and male prowess, precipitating a
wanted marriage or easily remediable through abortion.
Several program-oriented recommendations are evident
from this study. This study has clear lessons for the content
of interventions targeted for marginalized young males in
Duri as well as in other slum areas. Misconceptions and lack
of complete awareness about sexual risk behaviors must be
addressed in ways that are acceptable to the peer network;
messages concerning condom use in particular must be
reinforced, given the widespread resort to sex workers and

call girls. Youth must be educated as to the potential risks
of drug abuse and its links to risky sexual behavior and the
spread of STIs and HIV/AIDS.
At the same time, it is evident that young males are in
need of adult counseling and support. A frequently-mentioned
concern revealed in the FGDs and interviews was the lack of
opportunities to discuss sexual health issues with adults, be
they counselors, parents, or providers. Indeed, the need for
programs that provide mentoring relationships with key adults
was a recommendation made by young people themselves.
Therefore, on one hand, programs that foster these mentoring
relationships are needed. On the other hand, programs that
are addressed to educating parents about sexual health issues,
reducing their inhibitions about communicating sexual health
messages with their children and enabling them to provide
support and counseling to their children are also needed.
Clearly, the current in-school focus of sexuality education
must be expanded to reach out-of-school youth as well. Given
the importance of peer networks and the visibility of the
tongkrongan in Duri, programs and interventions are needed
that are acceptable to and engage young people through
these networks. Non-governmental organizations may play
a vital role in fostering such programs at tongkrongan and
peer network levels. The findings of this study suggest that
a promising mechanism may be the use of trained local peer
leaders to provide this education.
Most important, however, is the obvious need for special
efforts that address the environmental factors that have
contributed to the extreme vulnerability of the young males

in this study–notably poverty and lack of economic and other
opportunities. There is an urgent need to engage young males
and females in urban slums, through life and vocational skill
building, employment opportunities, and other recreational
activities.
Acknowledgement:
This study was supported by a grant from the Special Programme of Research,
Development and Research Training in Human Reproduction (HRP), World
Health Organization, Geneva. It benefited from the contribution of many
individuals. In particular, I would like to thank the staff of HRP Shireen Jejeebhoy,
Nicky Sabatini-Fox, and Iqbal Shah for their assistance. Special thanks goes to
Shireen for her endless support and patience. My sincere gratitude to my research
colleagues of CSDS, Atma Jaya Catholic University–Wempy Anggal, Adhe
Prasasti, and Plamularsih Swandari–for their cooperation during the eighteen
months of intense fieldwork and analysis. Above all, I would like to express my
deep appreciation for the young research participants and the local research team
(the so-called Tim-10) who participated actively in the whole research process.
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underserved Indonesia youth: A multi-phase participatory action-
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✤✤✤
Sexual
Behavior
of Street Gangs
in Davao City
Philippines
Sexual Behavior of Street Gangs
in Davao City, Philippines
Marigrace B. Duropan, Grethyl Gumagay,

and Leah Mae Jabilles
Introduction
Among the crowds of the people flocking to Davao City in the

Philippines are a large number of adolescents encountering
complex problems in many spheres of their lives. Many of
these young people join street gangs and are reported to
be sexually active with multiple sex partners among gang
members. The occurrence of buntog (the use of a female as
a sex object for gang initiation) has become an alarming
phenomenon. Young females are also becoming involved in
street gangs, even if the initiation rite is to have sex with an
older member or multiple members of a gang.
Gangs are structured and membership is achieved
through an initiation rite that tests loyalty and perseverance. In
the context of Davao City, buntog comprises the major activity
of adolescent street gangs as part of the gang’s rite of passage.
The main functions of a gang are to provide its members
with protection, happiness, and assistance in times of need.
Provisions include food, clothing, shelter, and other daily
necessities. Crucially, gangs must have a founder or leader

and the gang members’ names are recorded on a formal list. A
gang lays claim over a physical space, jurisdiction, or territory1
and established gang rules dictate that gang members must
ask permission from their founder whenever they have to go
somewhere.
As observed in this study, young people who join street
gangs mainly belong to the marginalized sector of society and
their ages range from 12 to 19 years old. Both male and female
street adolescents join gangs for companionship or identity.
Other reasons include emotional support, common interests,
fun and enjoyment, casual sex, curiosity, and protection in the
streets. These reasons explain why street cliques or peers are
potent forces in young people’s lives. This research reveals
that it is not just the individual’s own misconduct, failures
and interests that may lead him or her to join a street gang,
but also his or her socio-cultural environment that influences
behavior and personality.
Objectives
The objectives of this study are to increase awareness among

young people and to help them understand the situations
and conditions of street gangs. The goal is to provide young
people with general knowledge so that they can balance their
perspectives on sex. For policy makers, governmental, and
non-governmental organizations, this study aims to contribute
towards the re-examination of existing policies and programs,
1
Participatory Action Research, Tambayan, 2000.
Sexual Behavior of Street Gangs in Davao City, Philippines
to modify the current provisions so that they more effectively

address youth problems. For parents, community leaders,
and academics, the study offers additional references for the
examination and identification of possible ways to educate
young individuals by integrating social skills, training, and
information.
Methodology
This study of gang member sexual behavior was conducted

in the Bankerohan and Barrio Patay areas of Davao City.
These areas were purposively selected because they are
street gang territories and commonly served by the social
welfare agencies. Data collection was conducted during July
to September in 2001.
The subjects of the study are young males and females
aged 15 to 21 years old belonging to street gangs served
by selected governmental and non-governmental social
welfare agencies of Davao City, such as City Social Services
and Development Office, Pag-asa Home Center for Girls (a
temporary shelter), and Tambayan (a drop-in center). Subjects
belonged to the following street gangs: NOTORIUS, SUSPEK,
Pinanganak Upang Maging Astig, 24 ORAS, and Barpa Young
Killer. Street gang members chosen for inclusion in the study
were young people between 10 to 19 years old who were
willing to be covered in the study and who had utilized the
services of the social welfare agencies mentioned above. Both
Pag-asa and Tambayan helped in initiating contact with the
participants of the study.
This descriptive research used qualitative methods of

data collection including focus group discussions (FGDs) and
in-depth interviews. Interview guide questions for both the
FGDs and in-depth interviews were formulated in the local
dialect (Bisaya), based on consultations with experienced
researchers and review of the relevant literature. Questions
were finalized in consultation with the staff of the Pag-asa
Home Center for Girls and the research advisors.
The two sessions of FGDs held with the Bankerohan and
Barrio Patay area gang members involved 15 respondents per
area (7 males and 6 females). Male and female respondents
were separated into same-gender groups to enhance
privacy, disclosure, and openness among the respondents.
Additionally, in-depth interviews were conducted with six
respondents per area (three males and three females). Some
of these in-depth interviewees also participated in the FGDs.
In total, there were 30 respondents for the FGDs and 12
respondents for the in-depth interviews. All the FGDs and
in-depth interviews were recorded and from the interview
transcripts, researchers identified the main concepts needed
for a detailed, comprehensive presentation of information to
meet the objectives of the study. Triangulation of different data
from FGDs and in-depth interviews was done meticulously.
Direct quotes from the participants are used.
This study examines selected members of street gangs
in terms of:
• socio-demographic characteristics (age, sex, religion,
education, ethnicity, and occupation)

• family background (marital status of parents, family

composition, number of siblings, and migration status)
• economic characteristics (occupation of the parents
and other family members, earnings to support daily
consumption needs)
• substance use (present activities related to smoking,
drinking of alcohol, and the use of the prohibited drugs)
It also describes the dimensions of sexual behavior of the

street gangs members in terms of:
• age at sexual debut
• number of sex partners (total number of sex partners
starting from sexual debut)

• number of current sex partners
• frequency of sexual intercourse (within the past one
month)
• timing of intercourse (in relation to the female menstrual
cycle)
• specific sex practices (anal, oral and vaginal sexual
activity)
• behavioral characteristics of sex partners (attitudes and
practices of male or female sex partners during sexual

intercourse)
Finally, the study examines the support services available to

the street gangs from governmental and non-governmental
organizations.
Background Characteristics of the Respondents
Socio-demographic characteristics
Of the 30 respondents in the study, 17 were male and 13

were female, and it was noted that it was easier to encourage
males to participate in this study. Most of the respondents
(67 percent) were aged 15 to 17 (minors) and the rest (23
percent) were aged 18 to 19 . All of the respondents were born
in Davao City, currently lived there, were Roman Catholics,
and belonged to the Cebuanos ethnic group. Thirty-seven
percent had acquired primary education, 60 percent of the
respondents had acquired secondary education, and only
three percent had reached college level. As explained by
FGD respondents older than 17, the most common reason
for not reaching college was the financial constraints of their
families.
Family background
Most of the respondents in this study belonged to large

families, with four to six brothers and sisters. About half of
the respondents reported that their parents were currently
married and living together. Some 30 percent had parents who
were separated, while 7 percent of the respondents’ parents
were already widowed, and 13 percent of the respondents’
parents were not legally married.
Economic background
All of the respondents reported that their parents had low-

paying, irregular jobs that did not require a high level of
education. Almost half (43 percent) of the respondents’ parents
were laborers, particularly in Bankerohan where Davao City’s
biggest public market is situated. Other occupations included
vendors (23 percent), welders and drivers (13 percent), and
the privately employed (7 percent) who earned a meager
income. Almost half (40 percent) of the respondents’ families
had a monthly income of P 1,999 to 2,999 (about US$40-60).
Approximately 43 percent of the respondents’ families had
a monthly income of P 3,000 to 3,999 (about US$60-80), and
approximately 17 percent had a monthly income of P 4,000
to 4,999 (about US$80-100). The mean monthly income was
P 3,366.17 (about US$66).
Substance Use
Cigarettes
This study examined the respondents’ age when they first

started smoking cigarettes, the persons influencing them to
smoke, the average number of cigarettes currently smoked per
day, the cigarette brands usually smoked, sources for buying
cigarettes, reasons for smoking cigarettes, and any plans to
quit smoking.
All of the respondents reported that they smoked

cigarettes. Some of them smoked up to five cigarettes a
day but many smoked more than ten cigarettes a day. They
usually smoked Hope, Phillip Morris, and Winston cigarettes,
which cost P 1.75 to 1.00 peso per cigarette. Additionally,
they usually shared cigarettes with friends, which cost them
more. Most of the respondents said that their peers greatly
influenced them to smoke: “I learned to smoke because this
is one way of being in with the group. It is also a symbol of
being macho, especially for us boys.”2 Some of them said they
were influenced by their parents, while a few stated that they
smoked out of their own will.
When asked if they intended to quit smoking, many of
them said not in the near future, since they still enjoyed doing
it together with their peers. Others replied, “Maybe when I
get married and have children, I may be motivated to quit
smoking, to cut down cost.”3
Alcohol
Various dimensions of alcohol use were also examined in this

study. Questions were asked regarding respondents’ age when
they had their first drinking experience, brands of liquor that
they had tried drinking, sources for buying liquor, frequency
of drinking, persons influencing the respondents to drink
liquor, venues for drinking sessions, and the occasions that
prompted respondents to drink hard liquor.
2
FGD, July-September 2001.
3
Responses demonstrated that drinking usually began at

an early age. One male respondent recalled, “I started to drink
when I was ten years old, just to experiment. I liked it so I just
continued.”4 Alcohol preferences were influenced by different
factors such as price and flavor: “We like to drink Tanduay
because it’s less expensive,” and “We also like to drink beer
like Red Horse or San Miguel, but sometimes we also try tuba
(coconut wine) or lambanog (rice wine).”5
The girls also engaged in hard drinking with the boys.
Mostly, they did this during birthdays, fiestas, wakes, and
other social occasions.
Most of these young adults got money to buy liquor by
working in the market, while some used their allowances to
buy alcohol. Some respondents also borrowed money from
their friends and neighbors, while others mentioned that they
set aside some money for drinking.
I often do labor in the market during early morning and

late in the afternoon when the customer demand is at
the peak. The work is really heavy and hard, especially
as I’m still young. But thinking of the money I will
earn, so that I can join the drinking session, drives me
to work more, to earn more.6
Some respondents stated that they drank hard liquor so

that they could temporarily forget their family, financial,
or emotional problems. Others drank to get to sleep easily.
4
5
6
FGD, 16-year-old male, July-September 2001.
However, the majority of respondents revealed that they

drank for fun: “It is so much fun to drink with the barkada
[peers], sometimes we do it as often as two or three times a
day, especially during special occasions.”7 A few respondents
claimed they were allowed to drink in the presence of their
relatives and even with their own parents.
Before, I didn’t used to drink hard liquor, but seeing

my father getting drunk almost every night, I started
to do the same thing and enjoy it.8
Drinking sessions often take place at hideouts, according to

most of the respondents. For example, the street gangs in
Agdao congregated along the seashores, while the street gangs
in Bankerohan frequently used highway underpasses as their
hideouts. Some respondents used the houses of friends as the
locale for their drinking sessions, especially if parents were
not around. A minority of the respondents reported drinking
liquor at the stores where they had bought it.
All of the respondents admitted that they currently
drank, especially if they were to attend some important
occasions like fiestas, birthdays, and weddings. A few of the
respondents said that they only drank if they had enough
money to buy alcohol.
7
8
Prohibited drugs
Regarding the use of illicit drugs, this study examined

respondents’ age when they first used drugs, the kinds of
drugs used, sources for buying drugs, reasons for taking
drugs, persons influencing them to take drugs, the locales for
drug use, occasions that triggered respondents to take drugs
and plans to quit using prohibited drugs.
The majority of the respondents had experimented with
prohibited drugs like marijuana and shabu (methamphetamines).
They also used rugby and cough syrup. Some first tried drugs
when they were aged 10 to 15, while others had started later,
between the ages of 16 to 20.
I never intended to take drugs, since I know and have

heard of the bad effects it can bring, but I was triggered
by my curiosity and eagerness to belong to the gang.
I did and it just feels good.9
Money to buy such drugs and addictive substances came

from friends, doing labor, and allowances. A few respondents
admitted that they stole money to support their substance use:
“At times, given no choice and pushed by the desire to take
drugs, I steal money from my parents to get satisfaction.”10
The majority of the respondents revealed that their peers
most likely influenced them to take drugs. Various reasons
were given for continuing to use drugs, such as to help to
forget financial and family problems, to fall into a deep sleep,
and to stimulate appetite for food. As mentioned, most of the
9
Interview with 19-year-old female, July-September 2001.
10
respondents used drugs in the company of their peers. Some

engaged in drug use with their neighbors, and a few used
drugs with their relatives. These drug sessions usually took
place at hideouts, which were sometimes the drug dealer’s
house or a friend’s house when nobody was around. The
occasions that prompted drug use for most of the respondents
were birthdays, weddings, wakes, and baptisms. This pattern
implies that most of the respondents were not habitual users
or addicts, although a few reported they had become addicted
to taking drugs.
When asked if they had plans to quit using drugs, most
of the respondents stated that they did not because they could
not refuse when their friends offered them drugs. However,
for those who replied that they did plan to quit, they realized
it meant avoiding temptations and starting a new life.
Dimensions of Sexual Behavior
Sexual debut
The majority of the respondents first encountered the word

“sex” during the age bracket of five to ten years old. Some
understood the word “sex” as sexual intercourse, others
comprehended it as bastos (something malicious), while some
interpreted it as mandiri (something unpleasant).
It should be noted that the personal sources of
information about sex mostly came from their peers, gang
mates, or neighbors. They also learned about sex from video
tapes, lewd television shows, magazines, comics, and other
reading materials. Thus it can be inferred that curiosity about

sex was prompted by mass media and that sexual activity
was influenced by peer pressure.
I started to engage in sexual activity after I and my

barkada watched X-rated movies together with the girls
who also showed interest and motives to do sexual
favors with us.11
Triggered by curiosity and pressure from their peers, some

of the respondents engaged in sexual intercourse as early as
ten years old. One female respondent reported that she was
sexually abused at a young age, and this led her to engage in
sexual activity from then on.
I was an incest victim. I was sexually harassed and

molested by my uncle when I was 6 years old. I never
did anything to defend myself because he threatened
to kill my younger sister and do same thing with her
if ever I told anybody what he did. I suffered a lot.
I just had to bear the pain of what he was doing to
me, giving in to his sexual demands especially when
he was drunk. Fortunately, I was able to escape from
my uncle’s sexual abuses when he died of cardiac
arrest.12
Others had their first sexual experience as early as 11 years

old, while the rest were between the ages of 16 to 20 years old.
11
12
The main reactions or feelings respondents had toward their

first sexual experience were: lami (it was good), nakuryentehan
(electrified) and kapoy (tiresome). Some respondents mentioned
fear of bearing or fathering a child.
Number of sex partners

Study results showed that the female respondents were more
likely to have more sex partners than the male respondents.
The girls, labeled as buntogs, were used as bait to entice
other young males to join gangs. Although these girls were
used as casual sex objects, they reported that they did this
voluntarily.
We [the girls] are one of the reasons why many of the

boys join the gang. They can enjoy free sex and as long
as many are interested to have sex with us, it would
always be our pleasure.13
Another female respondent described having many sex

partners as being a status symbol: It’s OK for me if many guys
want to have sex with me because this means that I am more
beautiful than the others.”14
Respondents were asked how many sex partners
they had during the past three months. Most of the males
responded that they had one to five sex partners, and some
had six to ten sex partners. For the females, most of them had
six to ten sex partners.
13
FGD, 16-year-old female, July-September 2001.
14
Interview with female, July-September 2001.
Based on the results, it appeared that females had

more sex partners than males because females were used
to entice other males to join the gangs. Some of the females
reported that they not only derived satisfaction during sexual
intercourse, but they also enjoyed the appreciation from their
gang mates who viewed them as sex providers.
Such increased sexual promiscuity among young
adolescents also brought significant changes in their behavior
and attitudes toward sex. In addition, some of the respondents
had already experienced STDs, abortions, and other sex-
related problems as a result of their increased promiscuity.
My first sex experience was with my boyfriend. All the

while I thought that we would stay together and have
a family of our own. Unfortunately, I saw him having
sex with another girl. It shattered all my dreams and
plans for us. Such experience triggered me to do the
same and since then I’ve had multiple sex partners.
Lately, I had been infected with gonorrhea.15
One male respondent admitted during an interview that

his girlfriend had gotten pregnant and underwent abortion
through the hilot or massage method. He was informed about
the abortion after it happened but did not bother to think
about it. For him, the decision made by his girlfriend was
much better, since he was freed from any obligations and
responsibilities.16
15
16
Interview, July-September 2001.
Frequency and timing of sexual intercourse

Respondents were asked how many times per week they
engaged in sexual intercourse. The majority of males had
sexual intercourse three times a week, some engaged in
sex once a week, others twice a week, and a few had sexual
intercourse five times a week or more. The females reported
a slightly higher frequency of sex than the males; most of
them had sexual intercourse five times a week and more. The
females also reported engaging in repetitive sexual rounds;
as many as six rounds per encounter.
It feels good to stay active and alive after many rounds

of sexual intercourse. The more rounds of sexual
intercourse we engage in with our gang mates, old or
new members, the more likely the others will demand
to have sex with us and the greater authority we gain
with our barkada.17
All of the male respondents in this study reported that no

matter how frequently they engaged in sexual intercourse,
they never engaged in sexual intercourse during the monthly
menstrual period of their girlfriends or female gang mates.
The males considered it dirty, reported that there was a foul
smell and believed that they could possibly get infected with
STDs.
Most of us have engaged in sex several times; we can
no longer recall how many times we have engaged in
sex or with whom we did it. But one thing my friends
17
and I never do is engage in sexual intercourse during

the girl’s monthly menstrual period.18
Due to lack of effective education and information about sex,

the respondents appeared to be at high risk of contracting
STDs. Females were at high risk of unwanted pregnancy
since most of them did not regularly use contraceptives. The
few who reported using condoms during sexual intercourse
explained their fear of pregnancy and contracting STDs. In
addition, some males reported that after having intercourse,
when they knew that their girlfriends were fertile, they would
take certain precautions to prevent pregnancy.
Taking one to three tablets of Cortal [an analgesic]

with Coca Cola prevents pregnancy. This is taught
by a sister of one of my peers who is a midwife from
a public hospital. This practice is widespread among
adolescents who engage in sex but don’t want any
responsibility.19
However, some males also added that if they had sex with a
girl with whom they had no commitment, they simply did
not care at all to take any precautions.20
18
19
Interview with 18-year-old male, July-September 2001.
20
Interview with male, July-September 2001.
Specific sex practices
According to this study, the majority of the respondents

engaged primarily in vaginal sex, others engaged in oral
sex, and a few engaged in anal sex, especially those who
were involved in homosexual relationships. Five out of the
13 females interviewed said that they had never and would
not want to perform oral sex for their boyfriends because
they were not used to it.
A previous study found that variations in desired sexual
experiences of both male and female partners centered on
physical factors such as more frequent intercourse, more
foreplay, different intercourse positions, more time before
orgasm, available sex partners on a more frequent basis and
genital stimulation (Darling & Davidson, 1986). This statement
corresponds with that of the respondents, who cited different
styles and positions that they would most likely use with their
partners. Some also described that if intercourse was done
furtively, it was sometimes done in the “standing position”
or “sitting on the sink and on the bowl.” If intercourse was
planned, they usually preferred to perform the usual sexual
practices of vaginal sex, oral sex, and various other practices
and positions.21
Behavioral characteristics of sex partners
Sex without affection characterizes people having sexual

intercourse without emotional involvement, without the need
21
Described as “kissing from nail to the head,” “licking from head to toe,” “lying down on the
table and doing the cartwheel position,” “scissor-like position,” “sitting on the chair,” etc.
for affection. They engage in sex for sex’s sake because they
like it, enjoy it, and do so without strings attached.
The current study reveals that respondents most likely
go to bed with persons with whom they have no intimate
relationship, just as long as they enjoy it. Yet the majority
of the males revealed that they had set criteria in selecting
a girl. Some males stated that their criteria was for a girl to
be pretty, pleasant-smelling, nice, hard-to-get, aggressive in
bed, and sexually experienced. However, male respondents
also cited that when they were high on drugs and alcohol,
usually physical characteristics did not matter at all, as long
as their sexual desires were fulfilled.
I prefer a sexual partner who has sexual experience, for

it to be satisfying. When I’m high on drugs or drunk,
physical attributes are no longer an issue, as long as
we both enjoy doing it.22
These statements also imply that some respondents likely

have multiple sexual partners without using protection. The
female respondents also reported having similar criteria for
sexual partners.
Support Services
This study also examined the respondents’ opportunities and

abilities to utilize the support services offered by the non-
governmental organization, Tambayan, and the governmental
organizations, City Social Welfare and Development Office
and Pag-asa Home Center for Girls.
22
Services offered
The majority of the respondents were aware of the presence

of both governmental and non-governmental social welfare
agencies. The respondents from Bankerohan, especially
females, were the most likely to seek help and consultation
from Tambayan and Pag-asa Home Center for Girls, since
these were agencies that provided services and programs
geared for street girls and street boys.
As revealed during the FGD, males did not usually
seek help from these agencies, usually citing laziness and
a preference for asking for help from their peers. Females
were reported as needing support services more than males
because they were the ones who had to face the consequences
of pregnancy and miscarriages.
We prefer to consult our peers if we have problems

because we feel comfortable sharing with them. We
believe that we don’t encounter as many problems
as the girls. Girls are different. They have more needs
because they are the ones who get pregnant.23
Services utilized
Most of the respondents in Agdao revealed that they

had availed themselves of some services being offered or
promoted, especially by Tambayan. In order to utilize these
services, they needed to be referred by professionals, semi-
professionals, or peers as walk-in and outreach clients. Most
23
of these services were educational sessions, orientations, or

seminars on HIV/STDs.
They often give workshops or do other activities.

They also encourage us to watch educational movies
or films, especially about AIDS and other sex-related
matters concerning reproductive health and sexuality;
we learn a lot from it. As well, other help made
available to us includes free medical services for those
infected with gonorrhea. A few take advantage of
the educational assistance from CSSDO-Pag-asa, the
temporary shelter, and other services available to those
referred by the center.24
The respondents were also asked about the similarities and

differences between the services they had acquired from the
non-governmental and governmental organizations. The
majority of the respondents disclosed that the programs and
services they had received were about the same. The only
difference reported was in terms of the rules and regulations
to be followed in the centers. Respondents revealed that the
non-governmental agencies were more lenient in terms of
their behavior and attitude and they were also more open
than the governmental agencies.
They allow us to smoke, as long as we finish our

tasks, like cleaning, washing the dishes, and cooking.
In the governmental organizations, they prohibit
smoking.25
24
25
Both Pag-asa and Tambayan imposed sanctions if the

respondents violated rules and regulations.
Both agencies (public and non government

organizations) punish us if we have been caught
doing something against the rules, such as smoking,
sniffing volatile substances, or violating the curfew
hours. But they are right in giving us punishment, so
that we can learn and refrain from doing it.26
Alternatively, some respondents reported being caught by

law enforcement and local authorities. Almost half of these
respondents revealed that they had been abused.
Some of us, caught by the police, were punished. We

were asked to clean the toilet of the police station.
Police also hit us. Some were physically abused and
sexually harassed, particularly the girls. We have also
been harassed by the police but we remain silent and
don’t bother to complain so that they will discharge
us the next day.27
Level of satisfaction from the services acquired
The majority of the respondents were not satisfied with the

services available to them, although they were thankful for the
existing services. Generally, the respondents did not speak for
26
27
themselves alone but for their peers in general. Most of them

felt they were deprived of the basic rights and necessities of
life, such as education, food, clothing and shelter. Thus, when
they were asked what services they would like to see offered,
they replied that services should not be limited to the level
of immediate assistance, such as film-viewing workshops,
functional literacy programs, and counseling. They hoped to
see services that offered a more long-term solution; programs
that would enable them to change the course of their lives,
such as free education, which for them is the only gateway
to a better future.
Recommendations
Based on the results and findings of this study, several

recommendations can be proposed for governmental and non-
governmental organizations, policymakers, and the existing
shelters for street boys and girls.
Firstly, governmental and non-governmental
organizations should provide educational assistance and
support for these young adults in order to enable them to
pursue formal studies and reach their goals and aspirations in
life. Education will make it possible for these young adults to
explore many different opportunities, develop their interests
and acquire knowledge and skills. Such educational assistance
should not be limited only to school tuition fees, but should
also include assistance for other school requirements and
opportunities that will help to widen their horizons.
Governmental and non-governmental organizations
should also establish public and private agencies for both
females and males who are believed to be facing multiple

problems, such as social, mental, physical, and economic
difficulties. These agencies should be established not simply
as drop-in centers, but rather as places where the clients
can stay and call their home. In this way, the programs and
services offered at these agencies will not be limited to short-
term solutions, but instead will be able to provide long-term
assistance that includes developing more emotional and
social support. Additionally, local government authorities,
in particular the police, should be more vigilant and humane
in their approach to these young adults. Law enforcement
authorities must realize that these young adults have basic
rights and should not be treated as criminals, harassed, or
abused.
Secondly, policymakers should carefully re-examine
existing policies and programs that contribute to the
betterment and interests of these young adults. Policymakers
should modify provisions as necessary so that these young
adults will not be a deterrent in their efforts to improve and
mobilize young people.
Thirdly, the existing support services, such as Tambayan
and Pag-asa Home Center for Girls, should explore
mechanisms and opportunities to provide for the educational
needs of the young adults who display interest in pursuing
an education. These support centers should also strengthen
their administration so they can better advocate and initiate
alternative courses of action for themselves as organizations,
enhance their participation in social activities, and promote
their own empowerment.
In addition, they need to initiate and implement

programs and services that will genuinely develop the self-
esteem of their clients, which will in turn enhance these young
adults’ capacity to protect themselves from various diseases
and harm; the more self-worth young individuals have, the
more likely they will value their own lives. Finally, support
centers should provide a value-oriented educational program
for the young adolescents to instill values that can help them
in making their lives more meaningful and productive.
References
Aldaba, L. E. (1969). Towards understanding the juvenile delinquency. Quezon

City, PI: Bustamante Press.
Bason, S. A. (1986). Gender stereotypes: Traditions and alternatives. Pacific
Grove, CA: Brooks/Cole.
Darling, C. A., & Davidson, J. K. (1986).. Coitally active university students:
Sexual behaviors, concerns, and challenges. Adolescence, 21, 403-
419.
Henslin, J. M. (1996) Essentials of sociology: A Down -to-earth approach.
Boston: Allyn & Bacon.
Henslin, J. M., & Light, D.W. (1996). Social problems. Englewood Cliffs, NJ:
Prentice Hall.
Parker, R. G., Herdt, G., & Carballo, M. (1991). Social culture, HIV
transmission, and AIDS research. The Journal of Sex Research, 28,
77-98.
Sanchez, C., & Agpaoa, F. (1987).Contemporary Social problems and issues.
Manila: National Book Store.
✤✤✤
Providing
Contraceptive
Services
to Unmarried Youth
in Vientiane
Providing Contraceptive
Services to Unmarried Youth
in Vientiane
V. Sychareun, T. Boupha, S. Kounnavong,

B. Thovisouk, K. Prabouasone, and V. Hansana
Introduction
Emerging evidence from the Lao PDR, as from many

developing countries, indicates considerable sexual activity
among unmarried youth. Nevertheless, contraceptive
practice remains limited and irregular. The adverse health
consequences of risky sexual activity are generally well
documented (Friedman, 1994) and include early or unwanted
pregnancy and childbirth, induced abortion, and STDs,
including HIV infection (WHO, UNFPA, & UNICEF, 1998).
Young people’s knowledge, skills and access to health services
are observed to be limited in many settings (UNFPA, 1997).
Four out of five young people living in developing countries
have inadequate access to reproductive healthcare (Friedman,
1994).
Despite these potentially adverse health outcomes, data
in Lao is limited and little is known about young people’s
access to contraceptive information, counseling, or services.
As in many traditional settings, unmarried young people

are likely to face a range of obstacles in accessing sexual and
reproductive health services or acquiring contraceptives.
These obstacles not only include embarrassment and
awkwardness about communicating contraceptive needs,
fears of disclosing sexually-active status, and facing negative
parental and community reactions, but also perceptions of an
unfriendly service environment with judgmental and hostile
providers who may violate confidentiality.
Few studies have explored the extent to which providers
themselves corroborate these perceptions. The objective
of this paper is to explore the experiences and attitudes of
providers in serving the contraceptive needs of adolescents
in Vientiane Municipality, providers’ perceptions of quality
of care, confidentiality, and privacy, and differences in the
experiences of formal and informal sector providers.
Youth Sexual and Reproductive Health:

The Lao Context
In many countries, the special needs of unmarried young

people are not yet perceived as important. In Laos, too,
sexual and reproductive health services for unmarried
young people remain inadequate. Indeed, access to sexual
and reproductive health services is quite different among
married and unmarried youth. Young people currently have
no access, in practice, to reproductive health services unless
they are married and aren’t embarrassed to openly discuss
their sexual activities. Accounts of young girls resorting to
unsafe abortions, engaging in risky behavior, and suffering
Providing Contraceptive Services to Unmarried Youth in Vientiane
from STDs are increasingly observed (UNFPA, 1997). The risks

of complicated pregnancy and delivery, induced abortion,
and sexually-transmitted diseases are higher for adolescents
than for adults (UNICEF, 1998). Rates of mortality and
complications from early pregnancy, whether resulting in
childbirth or abortion, are much higher for adolescents than
older women. Data on abortion and resulting complications
are lacking, but indications point to frequent practice by
adolescents (UNFPA, 1997). Although little is known about
the state of overall reproductive healthcare in Laos, some data
on fertility and family planning are available and indicate the
magnitude of the poor reproductive health situation (UNICEF,
1998).
Healthcare providers are divided into those in the
formal sector (for example, doctors, nurses, midwives, and
healthcare volunteers from the public and private sectors) and
the informal sector (including traditional healers, personnel
of drug stores, and personnel of guesthouses frequented by
young people in order to engage in sexual relations).
Family planning services are widely available in both
the public and private sectors. Private sector service providers
include not only private clinics and drugstores, but also
traditional healers and distributors at guesthouses. Public
sector services include government services that are provided
through Family Planning units located in hospitals and
Maternal and Child Health centers, and also through birth-
spacing village healthcare volunteers and community-based
distributors. Family Planning unit staff are responsible for
the distribution of contraceptives and provision of counseling
services.
Public sector services, including family planning and
birth spacing, pregnancy and maternal healthcare, treatment
of infections, and gynecological disorders, etc. are, in theory,
accessible to all, irrespective of age or marital status. However,
services tend to be of limited quality and not effectively
accessible to the unmarried, as confirmed in discussions with
care providers in a district hospital in Vientiane Province.
Further discussions reveal that while providers at such
government health facilities as the Family Planning unit are
responsible for the provision of contraceptive services, the unit
is attached to the Maternal and Child Health section, and is
not widely used by the unmarried. Indeed, unmarried young
females and males prefer to obtain contraceptive services from
private sector providers or pharmacies (UNICEF, 1998).
The difficulties faced by unmarried youth in
accessing services may, in part, be related to negative
attitudes of providers and poor quality of services. Yet
little is known about the perceptions of providers on
the provision of reproductive health services to the
unmarried. A recent UNICEF survey (1998) of the general
quality of reproductive health services in Laos concluded
that few facilities are equipped to provide the full range
of services, referral mechanisms operate poorly, and
links between different levels of the healthcare system
are inadequate, thus making it difficult even for married
women to obtain healthcare in emergency cases (UNICEF,
1998). Lack of accessibility, in terms of inconvenient clinic
timings, long waiting times, and excessive travel costs remain
a major constraint to utilization of these services. According to

a survey conducted in Laos (UNICEF, 1996), the main reason
reported by 59 percent of women for not attending prenatal
care services was distance to healthcare facilities.
Undoubtedly, the attitudes and levels of preparedness
of providers play an important role in service use, which is
particularly pertinent in the case of contraceptive service
utilization by unmarried youth. Studies in other settings
have noted that provider background characteristics can
significantly influence the quality of care they provide (Fields,
1980). Studies tend to document provider perspectives
from the personal experience of the patients, reports from
relatives and friends, reviews of health facilities, nature of
treatment provided, and attitudes towards the clients (Kanji,
Kilima, Lorenz, & Garner, 1995). These studies argue that
negative provider attitudes and discomfort in discussing
ethical, psychological, cultural, and biological dimensions
of sexuality inhibit youth from using reproductive health
services (Middleman & Emans, 1995). However, such studies
have rarely been conducted among unmarried youth or the
providers who serve them in Laos.
Methodology
This study was conducted in the central region of Laos

during the period of 2000–2001. Vientiane Prefecture and
Vientiane Province were selected not only because they
jointly comprise 18 percent of the Lao population, but also
because youth in these settings are more likely than those in
other regions to engage in risky sexual activity. Additionally,
a variety of providers serving young people’s sexual and

reproductive health needs exist in these provinces. Each
province contains nine districts and the sample of providers
was drawn from all nine districts of each province.
Data were drawn from a study of a range of providers
involved in supplying contraceptives and providing
counseling and information concerning contraception at the
community level. The study aimed to explore the extent to
which the providers served unmarried youth and the attitudes
and experiences of these providers. Categories of providers
were selected on the basis of findings from key informant
interviews concerning the array of both formal and informal
sector providers offering contraceptive information and
services to youth.
The study consisted of a mix of quantitative and
qualitative methods. In-depth interviews were conducted with
a total of 56 key informants. This was followed by a survey
of 250 providers–150 from the formal sector and 100 from
the informal sector. Participants were selected purposively,
using a quota sampling method. Formal sector providers
included 45 doctors, 35 nurses/midwives, 30 private clinics,
and 40 village healthcare volunteers; informal sector providers
included 20 traditional healers, 50 drugstore staff, and 30
guesthouse staff. Trained interviewers administered face-
to-face interviews. Care providers were asked to estimate
the proportion of unmarried youth aged 15 to 24 years who
sought their services, their experiences, attitudes toward
provision of contraceptive services to unmarried youth, and
their perceptions on the availability, confidentiality, privacy,
and accessibility of family planning services.

Frequency distributions were presented to describe
the perspectives and characteristics of providers and their
attitudes regarding contraceptive services. Much of the
analysis compared the experiences, attitudes, and behavior
of formal and informal care providers. This analysis was
undertaken using cross-tabulation measuring the variables in
categories or difference in means of the variables of interest
at an interval level. Qualitative data was coded based on the
major themes and analyzed by comparison between formal
and informal care providers.
Profile of Providers
A socio-demographic profile of providers (Table 1) reaffirms

substantial differences in education, training, and employment
status. While both groups largely comprise females, it is clear
that formal sector providers are, in general, more likely to be
well-educated and trained in reproductive and adolescent
issues. They are also more likely than informal sector
providers to be employed in the public sector.
Table 1. Socio-Demographic Profile of Providers
Formal Sector Informal Sector
Female (%) 73 59
Completed Higher
Education (%) 40 8
Working in Public Sector (%) 70 0
Mean Years of Experience 8.8 7.7
Some Training in Adolescent
Issues (%) 21 12
Total Number of Providers 150 100
Provision of Contraceptives to Unmarried Youth
Despite informal sector providers’ limited background in

serving unmarried youth, it appears that unmarried youth
may prefer to obtain services from them rather than from
formal sector providers. Asked to estimate the proportion
of unmarried versus married young clients served for
contraceptive services, both provider groups reported a
greater number of married young clients. However, while
informal sector providers estimate that about one in five
young clients served is unmarried (21 percent), formal sector
providers estimate that about one in six is unmarried (17
percent, p = 0.018). In-depth interview findings corroborate
these perceptions.
Table 2 reports provider experiences in serving
unmarried young males and females by various socio-
demographic characteristics.
The informal sector providers are more likely to supply
contraceptives to unmarried males and females than the formal
sector providers (79 percent versus 53.3 percent, p = 0.000,
respectively for males, and 70 percent versus 65.3 percent, p =
0.002, respectively for females). Clear differences are observed
in services provided by formal and informal sector female and
male providers. For example, female informal sector providers
are significantly more likely to provide services to young males
than female formal sector providers (93.2 percent versus 45
percent, p = 0.000, respectively). They are also more likely
to provide services to young females than are their formal
sector counterparts (89.8 percent versus 66.1 percent, p =
Table 2. Percentage Distribution of Formal and Informal Sector Providers in Providing Contraceptive Services
to Unmarried Young Males and Females
Provider Formal Sector Informal Sector All Providers (%)
Characteristics Provider (%) Provider (%) (N = in parentheses)
To Males To Females To Males To Females To Males To Females

Total: Provide % 53.3 65.3 79.0** 70.0** 63.6 67.2
Sex of Provider
Male 75.6 63.4* 58.5 41.5 67.1 (82) 52.4 (82)
Female 45.0 66.1 93.2** 89.8** 61.9 (168) 74.4 (168)
Age
< 44 Years 45.575 62.7 90.5** 79.4** 61.8 (173) 68.8 (173)
44 Years and Older 0 72.5* 59.5* 54.1 67.5 ( 77) 63.6 ( 77)
Education Level
Primary School [53.8*] [53.8*] 33.3 [33.3] 42.9 ( 28) 42.9 ( 28)
High School 47.4** 61.8** 85.7 75.3 66.7 (153) 68.6 (153)
College 60.7 72.1 [100.0] [87.5] 65.2 ( 69) 73.9 ( 69)
Training in ASRH
No 52.4 71.8 77.9** 69.5 64.6 (198) 70.7 (198)
Yes 55.3 51.1 [100.0 ]** 80.0 59.6 (52) 53.8 ( 52)
* p > 0.010.05. ** p = 0.0010.01. [ ] n < 20

0.001, respectively). Disparities in education level of providers

suggest that better-educated informal sector providers are
considerably more likely than their formal sector counterparts
to provide contraceptive supplies to the unmarried.
In general, both formal and informal sector providers
reported that they did not refuse to provide contraceptives
to adolescents. Yet it was informal sector providers who
suggested more strongly that it was their responsibility to help
youth to protect themselves and their partners from infection
and unwanted pregnancy. Even so, three in four male and
female providers acknowledged that unmarried youth do not
have adequate access to contraceptives. It is noteworthy that
there was no variation by age, educational status or type of
provider in this perception.
Experience in Providing Contraceptive Counseling to

Unmarried Youth
As may be observed in Table 3 below, large proportions

of providers, irrespective of type, report that they counsel
unmarried youth on contraception. For example, slightly over
80 percent of all care providers reported that they counseled
unmarried young males to practice contraception while
somewhat fewer (75.6 percent) reported counseling unmarried
young females. While formal and informal sector providers
are about as likely to counsel males on contraceptive use (80.7
percent and 80 percent, p = 0.896, respectively), formal sector
providers are significantly more likely than informal sector
providers to provide counseling to unmarried young females
(82.7 percent and 65 percent, p = 0.001, respectively). The

reticence of providers to discuss contraception with unmarried
young women is evident and it appears that trained providers,
irrespective of type, are more likely than others to engage
young women in discussions about contraception (59 percent
and 40 percent, p =.000 respectively).
Providers were uniformly more likely to report
discomfort in discussing contraception with unmarried young
females than with unmarried young males. For example, as
reported in Table 4 below, while 12 percent reported difficulty
in discussing contraception with unmarried young males,
22 percent were uncomfortable in engaging unmarried
females in such discussions. In-depth interviews with youth
suggest that although contraception may be discussed, the
discussion tended to be superficial, and providers in general
Table 3. Percentage Distribution of Counseling Young Males

and Females to Use Contraception
Formal Sector Informal Sector All Providers
(%) (%) (%)

Offered Counsel To To To To To To
on Contraception Males Females Males Females Males Females
Use
Yes 80.7 82.7** 80.0 65.0 80.4 75.6
No 19.3 17.3 20.0 35.0 19.6 24.4
** p = 0.0010.01.
were reluctant to discuss contraceptive options or explain the

advantages, disadvantages and ways of using different types
of methods. Reasons for this reluctance are also reported in
Table 4. Of particular interest is that all providers, irrespective
of type, tended to identify characteristics of youth–“shyness”
Table 4. Provider Perceptions on Client-Provider Communication and Factors Inhibiting Communication
Formal Sector Informal Sector All Providers
To Male To Female To Male To Female To Male To Female
Communication
with youth (%):
Never 14.6 10.7 8.0 13.0 12.0 11.6
Difficult 12.0 22.0 15.0 21.0 13.2 21.6
Somewhat difficult 8.7 15.3 15.0 8.05 11.2 12.4
Easy 64.7 52.0 62.0 8.0 63.6 54.4
Number of Providers 150 150 100 100 250 250
Main difficulty in
communicating with
youth:
Youth are shy 50.0 63.5 58.1 63.3 58.1 63.4
Youth do not cooperate 28.2 25.0 24.2 20.0 24.2 23.2
Youth do not understand 3.1 1.9 1.6 0.0 1.6 1.2
Provider is of opposite sex 15.6 5.8 9.7 6.7 9.7 6.1
Lack of resources 3.1 4.8 4.8 6.7 4.8 3.7
Provider is older 0.0 0.0 1.6 3.3 1.6 1.2
and “lack of cooperation” in particular–as the main reasons

inhibiting provider-client discussion of contraception. In
contrast, providers’ own inhibitions or discomforts were not
highlighted. For example, among formal sector providers, half
reported shyness in discussing these issues as a leading reason
inhibiting communication with unmarried young males, and
almost two-thirds (64 percent) reported shyness as the leading
obstacle in discussing these issues with young females.
Among informal sector providers, gender disparities were
not quite as stark (58 percent and 63 percent, respectively,
for males and females.)
A second major reason reportedly inhibiting effective
discussion with young clients was their lack of cooperation.
About one-quarter of all providers, irrespective of type,
reported that unmarried youth did not follow their
recommendations, tended to require extended counseling
and were otherwise difficult to convince or “did not listen”
to providers. For example, one provider stated, “It is difficult
to deal with unmarried boys because they do not listen
to the advice. After getting better, they return to their old
behavior.”15 Another provider commented, “Unmarried girls
are shy and they did not want to tell the truth.”16
Indeed, in the course of in-depth interviews, providers
focused on young people’s lack of cooperation in several ways.
They highlighted their failure to listen to advice, suggested
that they had problems in understanding information and
advice provided by providers, were unwilling to engage in
open discussion, and did not keep appointments or provide
15
Interview with 36-year-old female Informal sector provider, 15 February 2000.
16
Formal sector provider, 31-year-old female, 11 January 2000.
sufficient information to enable follow-up. Several informal

care providers also noted that young people could not always
afford the treatment or medicine prescribed.
A third reason was inhibition to discuss sexual matters
with providers of the opposite sex, indicated by 9.7 percent
and 6.1 percent of providers in regard to young males and
females respectively. This preference by youth for same-
sex providers has been reiterated in other studies as well
(Weisman, 1987). However, during in-depth interviews, one
informal care provider remarked that, “It is easier to talk
with female than male adolescents because they are afraid of
getting infections and perform as advised.”17 A male formal
provider said that, “Talking with male adolescents is easier
than female adolescents because the health providers are the
same sex as them.”18
Attitude to Provision of Condoms and Other

Services to Unmarried Youth
Findings have thus far suggested that providers do indeed

provide contraceptive services and counseling to youth, but
that a significant minority remains uncomfortable discussing
sexual matters with unmarried youth, particularly females. In
an attempt to assess provider attitudes and the extent to which
these might influence behavior, providers were asked to report
their reactions in various hypothetical situations. One such
situation referred to the provision of condoms to unmarried
youth (“What would you do if an unmarried eighteen-year-
old male/female came to you seeking condoms?”). Results
17
Interview with 35-year-old female informal sector provider, 5 January 2000.
18
Interview with 38-year-old male formal sector provider, 10 January 2000.
are presented in Table 5.

What is interesting is that the large majority of
respondents would indeed provide condoms–either free or
for a fee–to unmarried youth irrespective of sex. There is
evidence that providers are slightly less likely to serve young
women than young men, but the disparity is negligible.
Additionally, it is clear that while formal sector providers
are more likely than informal sector providers to supply
condoms to unmarried youth at no cost (about 26 percent
versus 1 percent, respectively), informal sector providers
are considerably more likely than formal sector providers to
sell condoms to unmarried youth (about 80 percent versus
33 percent, p = 0.000, respectively).
Analysis of the qualitative data reaffirms that the
majority of care providers hold positive attitudes toward
the provision of reproductive health services to unmarried
young males and females. Some argued that they provided
the same level of services for married and unmarried males
and females. For example:
The services providing to married and unmarried

youth are the same and the services to female and
male should be the same. But the examination should
be separated because they are shy.19
Care providers provide reproductive health services to

the unmarried youth in order that they can use services
and have knowledge how to [protect] themselves.20
19
Interview with 45-year-old female formal sector provider, 15 February 2000.
20
Interview with 50-year-old male informal sector provider, 13 February 2000.
Providers argued, moreover, that females must be informed

about preventing pregnancies and that contraceptives
must be provided to unmarried youth in order to protect
them from STDs and unintended pregnancies. However,
a considerable minority did continue to argue against the
provision of contraceptive services to unmarried youth, and
unmarried females in particular. Typically, they justified this
premise on socio-cultural grounds, maintaining that, “[It]
is wrong according to the Lao culture and customs and the
youth will continue to drink and play and the diseases will
be spread.”21
Confidentiality and Concerns about Privacy
In many studies, unmarried youth, especially females, cite

fear of violation of confidentiality and concern about privacy
as major barriers to seeking contraceptive services. In this
study, providers were probed about their attitudes and
experiences in this regard. Findings suggest that it is formal
sector providers who are more concerned with maintaining
the confidentiality and privacy of youth than are informal
sector providers.
Most providers, in both formal and informal sectors,
reported in both the in-depth interviews and the survey
that the services they provided were confidential: “We do
not inform parents if they are not present initially because
it would seem that they were accusing the children if they
21
Interview with 50-year-old male informal sector provider, 14 February 2000.
22
Interview with 35-year-old female Vientiane Municipality drugstore clerk, 15 January 2000.
Table 5. Percentage Distribution of Provider Responses to the

Question, “What Would You Do If an Unmarried Eighteen-
Year-Old Sought Condoms from You?”
Formal Informal All
Sector Sector Providers
Response to Request from
an Unmarried 18-year-old
Male
Supply at no cost 26.7 1.0 16.4
Sell unconditionally 33.3 82.0 54.0
Refer elsewhere, would not
supply 25.3 16.0 21.6
Provide advice, would not
supply 12.7 1.0 8.0
Response to Request from
an Unmarried 18-year-old
Female
Supply at no cost 26.0 1.0 16.0
Sell unconditionally 33.3 78.0 51.2
Refer elsewhere, would
not supply 26.7 20.0 24.0
Provide advice, would
not supply 14.0 1.0 8.8
Total Number of Providers 150 100 250
did so and this could impact back on them.”22 However, as

many as 18 percent of providers, irrespective of type, stated
that they did indeed inform parents if their unmarried
children had sought services from them. Some formal sector
providers mentioned that they informed parents if they know
their parents and believe that the parents could teach their
children.
If we know parents and we are neighbors, we should

inform the parents, so they can bring their child to us
23
Interview with 39-year-old female Vientiane Provincial Hospital, Family Planning Unit nurse,
21 February 2000.
for treatment or counseling.23
Formal sector providers discussed at length the measures

taken to ensure privacy and confidentiality. Many reported
that client records were private and access to these was
restricted to relevant health staff (and in cases of sexual
coercion, the police). In contrast, the majority of informal care
providers did not keep any records of patients.
Privacy in the course of consultation was another
measure cited by formal sector providers but not by those
from the informal sector. Formal sector providers were more
likely than informal sector providers to report that they had
access to a private room to provide services to adolescents
(among male providers, 80.5 percent versus 36.6 percent,
p = .000; among female providers, 63.3 percent versus 23.7
percent, p = .000). This was substantiated in the course of in-
depth interviews. Among providers in drugstores, privacy
was sometimes available.
If an adolescent comes to buy medicine, they stand

over the drug counter, so other people can see them. If
they come for treatment and examination, we have an
examination room for the patients.24
Similarly, providers in guesthouses acknowledged their

relative lack of privacy. In guesthouses, clients typically
sought condoms at the counter, although in some, clerks
attended to guests in their rooms to inquire about their
condom needs. Finally, among traditional healers, services
were typically provided in a home setting and privacy was
24
Interview with 30-year-old female Vientiane Municipality drugstore clerk, 25 February
2000.
rarely assured.
Despite these different perceptions, providers did
acknowledge the need to ensure privacy for young clients.
However, a few exceptions were evident. Some formal sector
providers argued, for example, that privacy need not be
improved, and some informal sector providers argued that
since their facilities were neither clinics nor hospitals, there
could be no expectation of privacy.
Discussion
Findings have suggested that providers are indeed influenced

by traditional Lao norms that disapprove of premarital
sexual activity and hence stigmatize unmarried youth,
especially females, who seek reproductive health services
(UNFPA, 1997). Findings suggest that unmarried youth
constitute a markedly small proportion of clients of both
informal and formal sector providers. Providers recognize
this and attribute the reluctance of unmarried youth to seek
contraceptive services to a multiplicity of obstacles. They
argue that it is primarily client-level factors, such as shame
and embarrassment at revealing a sexually-active status,
and facility-level factors, such as inconvenient locations and
timings, that deter unmarried youth from utilizing formal
sector services. Few providers, in contrast, point to provider-
level obstacles such as poor perceived quality of care or
threatening provider-client interactions that are articulated
by the youth themselves in many studies in other settings.
Findings also suggest that informal sector providers–
particularly female providers–are more likely to provide

services to unmarried youth than are formal sector providers.
Formal sector providers themselves acknowledge that
unmarried youth constitute a disproportionately small
component of their clients; informal sector providers in
contrast note that unmarried adolescents do form a somewhat
larger proportion of their young clients.
Providers point to several factors that may underlie this
preference. For one, informal health sector providers tend to
be physically more accessible, with facilities located close to
main streets, and services available at all times rather than the
more restricted timings of formal sector facilities. Another set
of reasons center on the greater anonymity that young people
perceive in seeking care from informal rather than formal
sector providers: Providers note that unmarried youth may
be less likely to fear lack of privacy or the chance of being
observed and identified as sexually active by neighbors and
acquaintances in informal sector facilities as compared to
government facilities.
Two additional potential factors may be identified
from this study. Providers themselves report a reluctance
to supply contraceptives to unmarried youth–about one-
third of the total indicated that they would only refer or
counsel youth rather than supply them with contraceptives.
Similarly, about one-third reported that they experienced
discomfort in communicating with or counseling unmarried
youth. While both formal and informal sector providers are
willing, for the most part, to provide contraceptive services
to unmarried youth, as many as two-fifths of formal sector
providers and one-fifth of informal sector providers would

not provide contraceptives, but rather, only referrals or
counseling. Among those who report that they are willing to
supply contraceptives to unmarried youth, only a minority
would do so at no cost. It is clear that the profit motive is
paramount in the willingness among informal sector providers
to supply condoms to unmarried youth. On the other hand,
it is formal sector providers who have fewer reservations
about providing condoms at no charge to unmarried youth
(government-supplied contraceptives are provided either free
or at a nominal charge). This study’s findings that providers
are willing to supply contraceptives to unmarried youth
differ from the findings of other studies (Hughes & McCauley,
1998).
Many studies have argued that fears of violation of
confidentiality and privacy are leading factors inhibiting
unmarried youth from accessing contraceptive services
and seeking healthcare. However, studies have also found
that when assured that providers will respect their rights
to confidentiality, unmarried youth are more likely to seek
healthcare (Lieberman & Freeman, 1999). Other studies have
also emphasized the importance of privacy in the context of
client-provider relations (UNICEF, 1996).
The findings reported in this study highlight the fact
that considerable proportions of providers do not maintain
the confidentiality of their unmarried young clients. On the
contrary, many perceive that it is their duty to inform parents
that their children are sexually active in the hope that parents
might exert influence on their children to refrain from sexual
relations. Similarly, privacy is rarely guaranteed, and informal

sector providers (be they pharmacists selling condoms or
traditional healers providing services within their own
homes) are less likely than formal sector providers to be able
to provide services in a private atmosphere.
Conclusion and Policy Recommendations
This paper has explored the perspectives of providers, in

both the formal and informal sectors, about the provision of
contraceptive services to unmarried youth in Lao. Findings
suggest that providers are aware that unmarried youth
remain somewhat reluctant to access their services, be they
in the formal or informal sectors. Nevertheless, informal
sector providers are preferred for the convenience, relative
anonymity and confidentiality they provide.
Findings are mixed, however, on provider perceptions
concerning the quality of care they provide. For the most part,
no more than two in three providers, irrespective of type,
feel comfortable discussing contraception with unmarried
young clients, and many attribute the poor quality of this
interaction to young people’s own discomfort, unwillingness
to listen, inability to understand, or lack of financial resources.
Interestingly, providers’ own discomforts are not highlighted
as a barrier to free communication.
A significant minority–two in five formal sector providers,
and one in five informal sector providers–appear unwilling to
provide contraceptives to unmarried youth and would only
provide referral services or counseling. However, among those
willing to supply contraceptives, the overwhelming majority

of informal sector providers are willing to provide fee-based
contraceptive services, while formal sector providers are
more divided, with many willing to provide services at no
charge. There is no question that informal sector providers are
interested in the commercial aspect of contraceptive service
provision.
Finally, findings demonstrate a relative lack of sensitivity
among providers for the confidentiality and privacy of
unmarried clients. In this respect, while formal sector
providers are more likely to be able to ensure privacy during
consultation, they are about as likely as informal sector
providers to breach the confidentiality of clients by informing
parents of their children’s request for contraceptives.
Caution must be exercised in generalizing from these
findings. In view of the fact that purposive sampling was
employed, the scope of analysis is limited and findings cannot
be applied to the general population. Findings are largely
descriptive, and may not be representative of Lao in general or
even of the Vientiane Municipality and Province from which
data are drawn.
Nevertheless, findings offer several recommendations
for action. Firstly, they argue for strengthening and reorienting
training for providers to incorporate new messages on service
provision to unmarried youth. This study has highlighted
the ambivalence of providers, and their discomfort in
communicating with unmarried youth and in providing
them with contraceptive supplies. Both formal and informal
care providers need to be trained in communication and
counseling techniques and skills necessary for serving

unmarried youth. Trainings must reinforce the concept of
young people’s rights to confidentiality, and must dispel
any doubts that contraceptive services for the unmarried lie
outside the mandate of formal sector providers. Informal
sector providers, likewise, need to be apprised of young
people’s rights and needs for information and counseling.
Secondly, there is a need to ensure that lack of financial
resources do not prevent unmarried youth from accessing
contraception. Findings have suggested that both formal
sector and, particularly, informal sector providers are
prepared to provide contraceptives at a fee, despite the
fact that government-issued contraceptives are available
at no charge. Efforts need to be made to ensure that young
people have access to free and continuous supplies of
contraceptives.
Thirdly, programs must ensure that quality services are
provided to unmarried youth. Specifically, programs where
unmarried young people have access to contraceptive services
and supplies in appropriate and acceptable ways, where
providers are equipped to provide information and counseling
as well as supplies and appropriate referrals, and where
efforts are made to ensure privacy and confidentiality.
Fourthly, there is a need to establish informational and
educational programs that enable young people to know
about and protect themselves from unwanted pregnancy,
disease, and abortion, as well as to be informed about their
own reproductive rights and rights to confidential services.
At the same time, efforts need to be made to raise public
awareness and acceptance of young people’s needs for

comprehensive and confidential sexual and reproductive
health education and services.
Findings suggest that these measures are a necessary
first step in providing youth-friendly contraceptive services
in Laos that would enable unmarried youth to overcome
provider-level barriers to accessing services.
Acknowledgments:
This study was supported by the Special Programme of Research, Development, and
Research Training in Human Reproduction (HRP), World Health Organization,
Geneva. Special thanks to Dr. Philip Guest and Dr. Shireen Jejeebhoy for their
technical assistance and encouragement.
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UNFPA/UNICEF statement, Geneva.
✤✤✤
HIV/AIDS
Telephone
Counseling
in Shanghai and
Guangxi, China
HIV/AIDS Telephone
Counseling in Shanghai and
Guangxi, China
Yanning Gao
Introduction
Hotlines in less-developed countries have proven to be an

important tool in HIV/AIDS prevention by meeting the
counseling needs of people living with HIV/AIDS (Jimerson
et al., 1991) and by referring them to the different facilities
and resources found in the social support system (Lugue,
1993). AIDS hotlines are effective components of various
information and behavior change programs in less-developed
countries because of their lower cost of information and
prevention counseling, easier access to resources, and better
protection of anonymity (Smith, Helquist, Jimerson, Carovano,
& Middlestadt, 1993). While HIV/AIDS information from
administrative agencies tends to be limited and indirect, and
information from the mass media is sometimes even incorrect
and confusing (Oishi, Osawa, & Mikami, 1993), the hotlines
can serve individuals’ personal, informational, and emotional
needs, and encourage communication with certain socially
devalued groups.
HIV/AIDS could become a national disaster for China.

One effective way to overcome traditional barriers to HIV/
AIDS control in China, such as the stigma that arises from
the idea that AIDS is a “psychiatric disorders,” may lie in the
application of HIV/AIDS telephone counseling. At least 67
HIV/AIDS hotlines were established throughout the country
during the last decade (G. R. Yang, G. R. et al., 1999). In terms
of HIV/AIDS control, HIV/AIDS telephone counseling
could play a relatively more important role in China than in
Western countries because of the accessibility of telephones
(one for every six Chinese) (Y. Yang, 2000) and limited access
to face-to-face counseling (Lee, 1996). Although there have
been previous reports on HIV/AIDS hotlines in China
(Bechery, 1996; Gil, 1993; Ma, 1998; B. Zheng, 1998), most of
them have focused on the quantity and content of calls, the
distribution of callers, caller risk behaviors, or were designed
from a health education perspective. There has been a lack of
research on calling situations and provider-caller interactions
on the hotlines, especially in high-level epidemic areas.
Additionally, there was no systematic study of the structure
and functions of hotline services and no comparative study
of related hotlines.
Objectives and Methodology
This study was conducted to investigate the features associated

with HIV/AIDS telephone counseling, the characteristics of
providers and callers, and relevant problems of the hotline
services in Shanghai and Guangxi. Shanghai Municipality and
HIV/AIDS Telephone Counseling in Shanghai and Guangxi, China
Guangxi Province were selected to represent the middle- and

high-level epidemic areas in China, respectively. The study
sites were the Shanghai HIV/AIDS Hotline and the Guangxi
HIV/AIDS Hotline, the most important hotlines in their
respective areas.
A multi-method approach was used to collect data,
which consisted of qualitative and quantitative methods
and document review. Fifteen providers were interviewed
in-depth: six in Shanghai and nine in Guangxi. Two focus
group discussions (FGDs) were held: one in Shanghai with
five providers, and another in Guangxi with nine providers.
Ten key informants were interviewed: six from Shanghai
and four from Guangxi. One hundred thirty-two calls were
recorded by providers: 58 in Shanghai from November 20 to
December 19, 2000, and 74 in Guangxi from November 27 to
December 26, 2000. Ethical issues were a major consideration
here. According to the principles of HIV/AIDS counseling
(WHO, 1990), personal information of callers was recorded
only after the main concerns of each caller had been served
and callers had agreed to allow their personal information
to be recorded. In order to obtain relevant documents, local
mass media were studied, related journals and publishers
were sought, and previous call records were collected. After
a pilot study, the fieldwork was conducted from November
20, 2000 to March 13, 2001.
A conceptual framework for this study is shown in
Figure 1. In terms of features of telephone counseling,
call characteristics were used to label the basic contents of
calls. Call functions were categorized as knowledge-giving,
Figure 1. Conceptual Framework for Research of HIV/AIDS

Telephone Counseling
Situational Analysis of HIV/AIDS Telephone Counseling
(Provider’s Perspective)
Characteristics
Features of Characteristics
of Providers
Telephone Counseling of Callers
Personal Call characteristics Personal

characteristics characteristics
Call contents
Counseling
backgrounds Counseling
backgrounds
Experience Call functions
Risk behaviors of
Orientations used the persons
Counseling process
Skills used concerned
Knowledge update
HIV risk-assessing, referral-guiding, and crisis-counseling

(Saunders et al., 1989; WHO, 1990). Ideally, the functions
represent the caller’s needs as assessed via bi-directional
communication, reflecting the epidemic and its problems,
and providing insight useful in predicting future needs for
service content. A three-stage telephone counseling process
(rapport construction, exploring and insight, and decision-
making) was set up based on Barry’s five-stage process
(1996). The concern with decision-making was identified from
empirical research on telephone counseling (Intarajit et al.,
1995; Bobevski, 1998) and AIDS counseling (WHO, 1990).
The characteristics of providers consisted of personal
characteristics and counseling background, the latter
consisting of selected factors identified in the existing
literature that had proven to be of importance. These factors
included related training and working experience, theoretical

orientations and counseling skills, and up-to-date knowledge.
The characteristics of callers consisted their personal
characteristics of callers and the risk behavior, according to
the callers themselves, of the persons concerned. This division
discriminated between callers and the persons concerned,
according to callers, in order to better reflect the reality of the
utilization of hotline services.
Setting
The Shanghai HIV/AIDS hotline was set up in 1993 and

operated by the Shanghai Municipal AIDS Surveillance
Center, in order to serve public needs associated with HIV
prevention according to a middle- and long-term national
plan for HIV/AIDS control. The Guangxi HIV/AIDS Hotline
was set up in 1989 and operated by the Guangxi Center for
HIV/AIDS Prevention and Control. Guangxi is located next
to Southeast Asia, a high-level HIV/AIDS epidemic area.
Establishment of a hotline was the only available choice to
help local people because of the limited resources at that time.
Each hotline had one telephone line. Both centers belong to the
local Centers for Disease Prevention and Control (CDC).
Characteristics of Calls
Providers agreed that the current number of calls was stable

at only two to three calls a day on average (which was
“acceptable” and not “a heavy burden”) because the hotlines
had not expanded and actively promoted their services during

the previous two years. The number increased, however, albeit
temporarily, after a related health campaign was held. Most
of the providers reported an increased number of calls after
World AIDS Day, but some in Shanghai disagreed. A trend of
increasing calls was seen in Guangxi, which had 10 to 20 calls
per month before 1996, 40 to 60 calls per month during 1996
and 1997, and more than 60 calls per month after 1998.
Callers were more likely to use the hotline services in
the early mornings and late afternoons and on Mondays
and Fridays, partly because of the influence of work hours
or weekends. As opposed to Shanghai, hotline services in
Guangxi were still available after 5 p.m. and on weekends,
which highlights the fact that Guangxi’s hotlines were more
easily accessible.
According to call records, each call lasted 7.9 minutes on
average (S.D. = 6.12), 4.2 minutes in Shanghai and 10.1 minutes
in Guangxi (F = 32.17, p = 0.0000). Most calls (73.3 percent) in
Shanghai lasted less than 5 minutes, while almost all the calls
(98.6 percent) in Guangxi lasted more than 5 minutes (c2 = 70.4,
p = 0.0000). Thus, call duration in Guangxi was longer than
that in Shanghai. This disparity could be the result of several
factors. Perhaps people living in a high-epidemic area were
more concerned than those living in a less-affected area. Or
maybe urban people tended to communicate with each other
in a more efficient manner. Or, perhaps there were differences
in the providers’ experience and related training.
Why did some calls last as long as 40 minutes, while
others were as short as one minute? According to one
particularly caring, middle-aged provider in Guangxi: “I often

spent 30 to 40 minutes for a call, and never worried about the
length of telephone counseling.” However, some reported
being concerned about time. As a result, they would finish
a call “within a few seconds” in order to “save the callers’
time,” or would not let a call “last too long” or “go into too
much detail” otherwise the caller might come to “depend
on” the provider. One provider reported that the callers
tended to want to get to the root of the matter. “The more you
would explain, the more questions they would ask,” she said.
However, some providers hoped that the call would end “as
soon as possible” when they were busy. In the extreme, some
providers admitted that sometimes “nobody likes to pick up
the phone” or some would even quickly nudge the receiver
off the hook to cut off the call.
Characteristics of Callers
Of 132 calls, 121 callers allowed their personal information to

be included in the study. Of 121 callers, 76.9 percent were male.
Some providers in Guangxi expected that female callers would
increase when HIV infection in their “boyfriends” increased.
The average age of the 101 callers who reported their age was
31 years old (S.D. = 7.8) with a range from 18 to 53 years old.
The average age of both genders was similar. Callers aging
from 25 to 34 years old accounted for 54.5 percent of the total
calls, which indicated that those who were in the sexually-
active period tended to use the hotlines more.
In FGDs, providers believed that the majority of
callers engaged in unsafe sexual behaviors, although some

demonstrated misunderstandings of casual sex. Some service
providers commented, “People who engaged in unsafe sexual
behavior are the most likely to use this hotline” or “Ninety-five
percent of callers were motivated by their own behaviors.”
Moreover, most providers believed that not many female sex
workers used the hotlines and that if they did, they did not
acknowledge their status. Certain female callers said they
had “several boyfriends” but it was often inferred that they
were female sex workers after further questions were asked.
To answer why female sex workers did not tend to use the
hotlines very much, a senior provider in Guangxi said:
Compared to users of sexual services, who may feel

regret after their short-term happiness, female sex
workers are engaged in occupations and earn money
from this job for existence. Even though they care
about their reproductive health, they have less access
to information or may think that AIDS is curable.
Because of their psychological obstacles, it is not easy
for them to doubt their own health and decide to use
the hotlines. Sometimes, it is not convenient for them
to talk about HIV/AIDS on the telephone. In addition,
the hotline numbers are often shown in newspapers or
on TV only, but usually the main information sources
for female sex workers are magazines. Moreover, they
might not trust government agencies.
Little information about IDUs (intravenous drug users) was

collected from calls, except for one from Guangxi. According to

providers, however, IDUs in Shanghai and Guangxi accounted
for over 90 percent and 50 percent of reported HIV/AIDS
cases, respectively. The senior provider had received a few
calls from IDUs before, but only those he had met previously
in his fieldwork. In general, he thought:
IDUs tend to be careful all the time in their lives. They

don’t trust information in the public. They tend not
to use the hotlines because they’re not sure what will
happen on the other end of the telephone.
Although it was difficult to identify callers’ occupations from

the telephone, some providers believed that most of the callers
were white-collar workers and a few were odd-job workers
from rural areas. A provider in Guangxi concluded that two
kinds of people most commonly used the hotline: those who
had engaged in high-risk behaviors and those who tended to
be over-concerned with their health.
Of 121 callers, only 99 callers said they were calling for
themselves, while nine (eight males) were homosexual, and
40 of the males had multiple sexual partners. At both of the
hotlines, caller sexual orientation was similar and gay men
tended to ask questions more directly when calling. However,
more callers in Guangxi reported having more multiple
partners than those in Shanghai (c2 = 11.49, p = 0.0014). Forty-
five out of 121 callers had tested for HIV before and 8 out of
45 were positive. Therefore, the callers were not a random
sample of those who engaged in high-risk behavior, let alone
of the general population.
Thirty callers had experienced hotline counseling before

they called the current hotlines, especially those callers in
Shanghai (c2 = 6.19, p = 0.0453), while only 5 out of 121 callers
reported that they had used face-to-face counseling before.
Of the 30 callers, 22 had used hotlines 2.8 times before on
average (but the range was from 1 to 20), while the others
could not recall the exact number of times they had used
hotlines. Interestingly, 67.3 percent of callers reported that
they would like to use hotlines again in the future, especially
those callers in Guangxi (c2 = 14.89, p = 0.001).
Characteristics of Providers
There were no volunteers or peer counselors at the hotlines.

All 15 providers were full-time staff of their respective centers.
However, being hotline providers was only a small part of
their job responsibilities. Of the 15 providers, there were 2
females out of the 6 providers in Shanghai, and 5 females out
of the 9 providers in Guangxi. The range of the providers’
ages was from 24 to 48 years old. Many providers in Guangxi
were younger than those in Shanghai and had just recently
graduated from universities.
All providers had a biomedical background, but none
had a degree in psychology or professional counseling.
However, before providing telephone services, 5 providers in
Shanghai and 8 providers in Guangxi received at least one or
more training courses, 2 providers in Shanghai and 7 providers
in Guangxi received at least 2 or more training courses, and 6
providers (all in Guangxi) received 3 to 4 training courses. On

average, providers in Guangxi and in Shanghai received 20.1
and 13.0 days of training respectively. Providers in Shanghai
were trained mostly in STD/AIDS counseling by the National
Dermatitis/STD Center (4 times), while their counterparts in
Guangxi were trained in pre- and post-test counseling and
counseling skills (8 times), interpersonal communication
and counseling (4 times), psychological counseling and
HIV/AIDS counseling (3 times each). These trainings were
provided by 3 well-known universities in China (9 times in
total), Chiang Mai University in Thailand (twice) and national
HIV/AIDS or health education agencies (8 times in total).
Generally speaking, providers in Guangxi were trained more
often, for longer periods and in broader content than those
in Shanghai, which might help to explain their counseling
behavior to a certain degree. They spent more time per call,
made themselves more available for the hotline services, and
had more experience in exploring callers’ crises.
In Shanghai, 4 out of 6 providers had 2 years of experience
at a local STD outpatient clinic. However, of these 4 providers
who use to be STD physicians, one defined “counseling” as
being involved “every time one is diagnosing and treating
STD patients,” while another thought that “hotline counseling
is simpler than providing STD outpatient service.” They
regarded their previous outpatient service as qualifying them
to provide counseling. One explanation may be that in the
Chinese language, “counseling” means either “information
counseling” or “psychological counseling,” which could have
allowed them to ignore the latter.
In terms of knowledge updating, a provider in Shanghai

said that the training module on HIV/AIDS counseling was
not suitable since it did not fully represent the reality of
counseling in China, let alone the more specific aspects of
HIV/AIDS telephone counseling. However, a provider in
Guangxi pointed out that what they needed was training
material that focused directly on common questions that were
designed specifically for HIV/AIDS telephone counseling.
Another provider believed that interpersonal communication
and counseling skills could not be learned from books or
training, but rather only from “experience.”
Interactions Between Callers and Providers
In Shanghai, providers found that generally callers tended to

prefer to talk to the opposite gender, especially when in need of
psychosocial counseling, but some female callers hung up the
phone when they heard the voice of male providers. Providers
speculated that these females were probably hesitant to talk
about their sexual behavior with male providers, especially
regarding heterosexual behavior. Alternatively, some male
callers were silent when female providers picked up the
phone. A female provider said:
Sometimes there’s no voice over the phone when I pick

it up and then it’s hung up by the caller. I guess perhaps
a gay caller preferred a male provider answering the
phone. I asked my male colleague to pick up the next
call when I guessed it might come from the same
caller.
Similarly, but only in Guangxi, homosexual callers often asked

to talk with older male providers or directly with “Dr. Liu,”
an experienced female provider for homosexual counseling.
Some long-distance callers had called many other hotlines
before and knew “Dr. Lui’s” name from their gay friends.
Besides “Dr. Liu,” callers tended to talk with the providers
who had satisfactorily served them before (e.g., “Dr. Liang”
in Guangxi and “Dr. Fang” in Shanghai). Interestingly, there
were four types of interactions between callers and providers
relating to gender and age:
1. Callers with providers of the opposite gender

(psychosocial issues)
2. Homosexual callers with elder male providers or
experts (homosexual issues)
3. Female callers with female providers (sexual issues)
4. Callers with providers mentioned by name
(unspecified)
Contents of Calls from the Callers’ Perspective
The concerns of callers were classified into 7 major topics,

in which a total number of 285 questions was asked by 132
callers. On average, a caller asked 1.5 questions in Shanghai
and 2.7 questions in Guangxi. Over 70 percent of questions
asked by callers focused on three topics: HIV testing,
transmission modes, and psychosocial issues (see Table 1,
Column 2; N=285).
In general, the content of calls changed after HIV/AIDS

knowledge became better known because of health education
or the accumulated impact of mass media. Although the
number of calls did not increase, callers tended to ask more
behavior-related questions than before. A provider estimated
that questions regarding safe sex, using clean needles/
syringes, masturbation, non-penetrative sex, oral sex, and
anal sex accounted for 2030 percent of calls. Other providers
attested, “It was impossible to ask such questions two years
ago,” and, “The questions focused more on knowledge
years ago, and focus more and more on HIV risk assessment
nowadays.”
In the past, the questions often focused on casual
contact, for example, whether shaking hands or kissing would
transmit HIV. More recently, callers have asked questions like,
“How long will it take for HIV/AIDS symptoms develop?”
after they had used the services of a KTV box,14 or, “What are
the early symptoms of HIV/AIDS?”
Sometimes one caller would ask several questions within
the same topic or across topics. Therefore, it was necessary to
count the questions according to each caller: over 50 percent
of callers asked about each of the three above-mentioned
topics (see Table 1 Column 3; N=132). Callers in Guangxi
asked more questions about HIV testing, transmission modes,
symptoms and disease, and psychosocial issues than those
1
A “KTV box” (“KTV bao fang” in Chinese) is a term used in China to describe recreational
services offered in a private room or box, sometimes consisting of sexual services.
Table 1. Topics of Caller’s Concerns in Shanghai and Guangxi
Total Shanghai Guangxi χ2 Test
Frequency Proportion % Frequency % Frequency % Statistic P
Topics ❑=❑+❑ ❑=❑/285 ❑=❑ ❑ ❑=❑ ¨ ❑=❑ ❑ ❑
/132 /132 /132
HIV Antibody Testing 68 23.9 51.5 23 39.7 45 60.8 5.83 0.02
Transmission Modes 66 23.2 50.0 18 31.0 48 64.9 14.89 0.00
Non-Risky Situations 25 8.8 18.9 12 20.7 13 17.6 0.21 0.65
Symptoms & Disease 39 13.7 29.5 9 15.5 30 40.5 9.78 0.00
Service for PLWHA* 4 1.4 3.0 3 5.2 1 1.4 Fisher 0.32
Facts of HIV/AIDS 10 3.5 7.6 3 5.2 7 9.5 Fisher 0.51
Psychosocial Issues 70 24.6 53.0 18 31.0 52 70.3 20.10 0.00
Not Classified 3 1.1 2.3 1 1.7 2 2.7 Fisher 1.00
Total 285 100.0
* People Living with HIV/AIDS
in Shanghai.
Of 68 callers who asked questions about HIV testing,

39 were concerned about the procedure of the test service,
while 15 and 17 asked about the testing window period and
interpreting test results, respectively. Interestingly, callers
in Guangxi asked more about “the window period” (c2 =
14.89, p = 0.001), testing site (c2 = 6.29, p = 0.0121), and the
cost of testing services (c2 = 11.30, p = 0.0008), while callers
in Shanghai asked more about the time when services were
offered (c2 = 8.32, p = 0.0039). Of 66 callers who were concerned
about transmission modes, instead of asking in a general
manner (19/66), more than half of them (35/66), mostly in
Guangxi, asked about sexual transmission directly, especially
for heterosexual behavior.
Of 70 callers confronted with psychosocial conflicts, the
most common issues were fear of HIV/AIDS infection (58/70).
The most serious issues were depression in HIV-positive
patients (20/70), especially those in Guangxi; worry, among
healthy-but-worried HIV-negative persons (13/70); and social
issues such as job loss or disclosure of HIV status (7/70).
Some gay men said that they felt oppressed by “The Three
Big Mountains,”2 a popular saying in Chinese. According
to some providers in Shanghai who were experienced as
telephone counselors in both STD and AIDS hotlines, the
callers of HIV/AIDS hotlines did have more complicated
psychological problems and were more difficult to deal with
than those of STD callers.
Among those psychosocial issues, a pattern emerged

of healthy-but-worried HIV-negative callers, who were
inclined to disbelieve that they had been tested and found
to be HIV-negative. As shown in Figure 2, if they exhibited
the following characteristics, they were defined as having an
“HIV-hypochondriac syndrome” in this study:
a) The callers had engaged in unsafe sexual behaviors

before or had experienced other clearly-defined risky
contacts.
b) They had quasi-HIV/AIDS-related symptoms,

especially those that made them physically unhealthy.
When they looked up relevant books, they found
their symptoms were “exactly” the same as the books
described. Providers regarded this phenomenon as
“sitting in the correct seat.”3
c) They were tested for HIV antibodies several times

in different places and results were always negative.
However, they did not believe the results.
d) They were familiar with “almost all” HIV/AIDS-

related knowledge, especially from books. They would
know, for example, that the human body sometimes
did not exhibit HIV antibodies or that in some special
2
This saying (san zuo da shan in Chinese) refers to imperialism, feudalism, and capitalism. This
is a political term used to describe the oppression of Chinese people before the establishment
of the People’s Republic of China in 1949.
3
This is a Chinese idiom (dui hao ru zho in Chinese) used to describe a situation where a client
finds the right seat in a cinema by checking his/her number of on their ticket.
cases in other countries, people had been found to

have AIDS but their HIV-status was never positive.
They could not be certain that they were 100 percent
negative.
e) They called the hotlines many times (at least 5 to 6

times, sometimes up to 10 to 20 times within a day).
Therefore, almost all providers could easily recognize
their voices on the telephone. A provider referred to
such calls as “old voices.” Interestingly, after providers
answered their questions, these callers might say that
they felt more comfortable. However, they would call
again with similar questions two to three days or half
a month later. None of the providers could persuade
them to stop obsessing and worrying, nor could
they convince the callers that they were 100 percent
negative
In Shanghai, all the providers mentioned two such cases

involving long-distance callers from Shandon province. Ms.
Fang, who provided more extensive telephone services than
her colleagues, mentioned that she received many calls from
callers who did not accept their HIV-negative status. Here is
a telephone case record from Guangxi:
The caller had multiple sexual partners two years ago

and he always feels that he has HIV/AIDS symptoms,
as described in books. In March 2000, he tested for
HIV antibodies the first time and the result was HIV
Figure 2. A Psychological Pattern of the HIV-Hypochondriac Callers
Precondition (Behavior):
Previous unsafe behaviors clearly defined as risky transmission
modes.
It is really possible for me to be infected with HIV
Existing-Condition (Illness):
Physical quasi-HIV symptoms
My symptoms are exactly the same as the books describe
HIV Testing (Disbelief): Hotline Counseling (Crisis):

Negative results. Repeated calls.
I do not believe the results of I understand and know all that. But
my HIV testing my situation is that . . .
Strengthening (“Knowledge” Gathering):

The results of HIV antibody testing can possibly be a
false-negative
It is possible for me to be HIV-positive because the results
are not 100% correct
negative. In the middle of April, he went to a CDC

clinic at the provincial level and tested again. The
result was the same. In early June, he came to our
center and tested for HIV again. His antibody was for
the third time negative. However, he does not believe
our testing results. He thinks we cheated him.
According to common sense, these callers would be expected

to be very happy to learn that they were HIV negative, so why
did they insist on believing they were HIV positive? From a

psychological perspective, providers offered their opinions:
There is a “psychological knot” inside their hearts,

which is never undone and this makes the person
suffer from neurosis.
The callers do not lack relevant knowledge. However,

“their minds are not able to change or be flexible when
feeling backed into a ‘psychological corner.’” 4
They cannot distinguish the small differences among

certain forms of dermatitis, then misinterpret symptom
A as symptom B, which is related to HIV infection.
They are hypochondriacs and have “a problem” or a
sensitive personality. They are not poor people, since
poor people must work hard to earn money, without
time to think in a sensitive, deep way.
From an interpersonal communication and counseling

perspective, providers gave their feedback:
They take unnecessary pains to study an unsolvable

problem. The results are unnecessarily doubted.
It seems like you must diagnose them as HIV positive

in order to serve their “needs.”
From the medical perspective, providers reported that

4
This saying (guai bu guo wan in Chinese) means that one is inflexible; literally, that one cannot
turn a corner, turn around, turn away, turn aside, or turn back.
such callers were nervous and fearful, with certain “forced

symptoms” or “AIDS neurosis.” Two providers diagnosed
them as having “STD/AIDS-phobic syndrome,” which made
them anxious, sleepless, and experience nervous system
disorders. At least two of those callers finally experienced
psychological breakdown, together with stress and family
conflicts. However, not every provider agreed on that
diagnosis. During FGDs, a provider in Shanghai mentioned
that she was not sure of this diagnosis, as the callers had
“forced symptoms.” In fact, she regarded those callers who
were the healthy-but-worried as “without any practical
[biomedical] significance.”
There were two other psychological patterns found
among hotline callers. One pattern involved some callers
who stated that they were calling for their friends, which was
not always true. These callers accounted for 17.4 percent of
callers (21/121). In Guangxi, one caller was discovered to be
actually calling for himself. Ms. Fang often discovered that
some callers, who initially stated that they were calling for
their “friend,” were actually calling for themselves. Then
she would point out: “The problems you want to solve are
the same, whether ‘he’ is your friend or yourself.” Another
pattern was related to euphemisms. Instead of stating “visiting
prostitutes” or “going whoring” over the telephone, some
callers might refer to such behaviors as “easy and elegant,”5
“on a business trip,” “pre/extra-marital sex,” “drunken
activities,” “a false step” or “being disloyal.”
5
This a saying (xiao sa in Chinese) used to describe casual and charming behaviors or behaviors
with grace and ease.
Functions of Calls from the Providers’ Perspective
The main topics of providers’ telephone services are

shown below in Table 2. Both hotlines primarily focused
on knowledge giving and information service and served
these original purposes well. However, hotlines adjusted
their services gradually because of the many psychological
issues that arose later. In Shanghai, a senior key informant
pointed out: “The more calls we had, the more social
problems we realized there existed.” Ms. Fang estimated
that currently about 50 percent of callers had psychological-
related problems. “They are unwilling to go to the Shanghai
Psychiatric Health Center for counseling, but like to use
our hotline as a means of psychological release,” she
said. However, directors of both hotlines realized that the
knowledge structure of their providers was neither adequate
nor suitable to provide psychological counseling: “[In
Table 2. Topics of Providers’ Telephone Services
Total Shanghai Guangxi χ2 Test
Topics Frequency % Frequency % Frequency % Statistic P
Knowledge Giving 69 52.3 22 37.9 47 63.5 8.53 0.00
Health Education 55 41.7 12 20.7 43 58.1 18.73 0.00
HIV Risk Assessment 54 40.9 15 25.9 39 52.1 9.69 0.00
Referral Guidance 22 16.7 7 12.1 15 20.3 1.57 0.21
Information Support 73 55.3 25 43.1 48 64.9 6.23 0.01
Psychosocial Support 12 9.1 5 8.6 7 9.5 0.03 0.87
Shanghai] our knowledge structure might not be competent

for psychological counseling,” and, “[In Guangxi] for certain
simple psychological problems, we can provide callers with
some coping skills to extend their ways of thinking. If these
skills are not effective for some cases, we suggest referral,”
they explained. Similarly, Ms. Liu said: “Our providers had
already met many psychological cases which are difficult
to deal with . . . we are in no position to help under such
circumstances.” Many mentioned that it was difficult for
them to provide crisis counseling, that they were exhausted
after doing so, and hoped that there would be other places
where callers with psychological problems could be served.
Therefore, the current major functions of the hotlines were
defined as “knowledge giving,” “information service,” or
“prevention” by their directors.
Relatively speaking, most providers believed that
they were better at knowledge giving and weaker at crisis
counseling. Fortunately, some were confident of their
counseling skills.
I can manage to deal with all telephone services. (Male

provider in Shanghai)
I am able to deal with all issues except those related

to sexual partners, pregnancy, and “HIV/AIDS-
hypochondriac syndrome”. (Female provider in
Guangxi)
I can enjoy crisis counseling. When I pick up a

telephone, I begin to play a role of telephone counselor.
After I hang up the telephone, I am often proud of
what I have done for my callers. (Male provider in

Guangxi)
However, there were two providers who reported that they
could deal with callers’ questions “basically” or “effectively,”
while their colleagues disagreed with them. According to
FGDs, one lost his temper once during telephone counseling,
while another invited a caller to the hotline for face-to-face
counseling after many episodes of telephone counseling,
but his colleagues did not believe that he was sufficiently
competent to deal with this case in an effective manner.
In reality, many providers were good at HIV risk
assessment, and tended to work as HIV risk assessors. One
expert in public health in Shanghai, Mr. Pan, defined it as
follows:
In technical terms, many current callers want us to

help them assess how much their probability of HIV
infection is according to their previous risk behaviors.
This is not the way of knowledge giving–that is a
special part of HIV/AIDS hotline services.
A provider in Guangxi explored his callers’ situations using

this method: First, he would ask himself why callers asked
such questions or whether the questions represented previous
experiences that disturbed them. Then, callers were linked to
a specific kind of risk. Some providers assessed their callers
in a more direct way: First, they would assess whether or
not callers were HIV positive; if not, then they would assess
whether or not they had engaged in risky behavior or had
had risky contacts and whether or not they were in or had

passed their window period. When callers were shy or hesitant
to talk directly, it was not difficult for providers to deal with
them. Because of the fact that local CDCs were authorized to
conduct HIV confirmation tests, it gave providers grounds to
explore callers’ previous behavior, then assess it by using the
following method: “If you want to do the test, please tell me
the truth. Otherwise, how can I know whether you need to do
it or not, or when it is the best time for you to do it?”
Counseling Techniques Used by Providers
Counseling process
The most popular way to build rapport was the use of

straightforward, ordinary greetings. Most providers thought
it was not difficult to communicate directly with callers,
since that was the callers’ original purpose in contacting the
hotlines. In a few cases, if callers hesitated to talk directly, Ms.
Fang successfully encouraged them by saying, “Now that you
have made this call, you should tell me what you want to
say.” Confidentiality was also an effective reason for callers to
communicate openly. However, there were a few callers who
hung up the telephone before rapport could be initiated.
Some providers (three in Shanghai, one in Guangxi) used
the concept of “main ideas” or “problems” to describe their
exploring process. Their method was to “catch main ideas” or
to “elicit main ideas” because most callers were not willing to
actively talk about their negative sides. Other providers (two
in Guangxi) used the concept of focusing on “the questions”
by either “holding the questions” or “following questions” to

“catch the sensitive points.” The idiom “skinning the problem
layer by layer”6 was also used by two providers to refer to a
different manner of exploring–one female provider tended to
“elicit” callers’ thoughts on a related topic that she initiated,
while one male provider was accustomed to explaining
something, then stopping to wait for callers’ questions in order
to form a two-way conversation. “Telephone counseling needs
a train of working [counseling] thought,” he said. According to
his experience, if he could not hold the question or talk to the
point very well, telephone conversation would become more
and more confused. “When touching the points, callers might
laugh and cry at the same time,” he said. On several occasions,
by skillfully choosing his words, he was able to successfully
help callers cope with their crises. However, not every
provider knew how to explore callers’ problems. Sometimes,
when callers rang the hotlines repeatedly and asked the same
questions as before, many providers just repeated the same
answers as before. Thus they were sometimes “repeating”
instead of “exploring.” “It is useless even if you explain 100
times,” “They never listen to you,” or “They don’t trust you,”
some providers complained about callers.
Finally, providers reported that they dealt with decision
making according to the main principles of counseling, that is,
showing the caller several options, explaining the advantages
and disadvantages associated with them, then letting callers
have the final power to decide. In short, most providers
thought that the process of telephone counseling tended to
6
This idiom (yi ceng yi ceng di bao in Chinese) means to explore the problem step-by-step, as
in “skinning an onion” “peeling a tangerine,” or “shelling peanuts.”
be more direct and flexible or less time intensive than face-

to-face counseling.
Orientations
None of the providers specifically mentioned anything about

client-centered orientation, cognitive orientation, or any
other orientation. One provider did not even understand the
term “orientation.” In Guangxi, however, some providers
mentioned that it was important for them to be concerned
with what the callers were experiencing and had tried to put
themselves in the callers’ position when they were listening to
them. Otherwise, the issue of orientation was not discussed.
Counselling skills used
• Starting the conversation
After a greeting, providers would say something like, “Can

I help you?” before introducing themselves. According to
Rosenfield (1997), hotline providers should let the phone
ring three times before they answer and let the callers know
that they have dialed the right number by greeting them with
“Hello” and providing the name of the agency.20 During the
fieldwork, nobody mentioned anything about this.
• Extra listening
Two providers in Guangxi mentioned that they made an effort

to notice callers’ voice tones. Nobody revealed an awareness
of background noises. Some providers discussed how they

dealt with silence. A provider in Guangxi believed that it was
important to recall callers’ emotional reactions just before their
silence. When callers were silent, usually he asked questions
like, “What are you thinking now?” or “What do you think
about it?” in a gentle manner, and was patient to wait for a
reply. In Shanghai, however, some providers felt strange when
callers neither spoke nor hung up the phone:
I just said, “Hi, can I help you? . . . Can I help you?” or

“Speak please,...speak please . . .” When there was no
feedback from the callers, “Hai,” a long sigh was given
by the caller, then the phone was hung up.
• Assessment
In Guangxi, one provider tried to assess callers’ feedback about

his counseling by asking them whether his explanations were
the same as other providers’ explanations. Other providers
assessed callers’ problems by asking whether callers had ever
talked to their counterparts before.
• Crisis coping
When providers were asked whether they used “harm

reduction” in telephone counseling, some in Guangxi said
“Yes,” and then spoke out the term in English even though
they were being asked in Chinese. Some providers in Shanghai
said “No,” and one of them misunderstood it as meaning “it
is not necessary to interfere in the callers’ sexual lives.”
• Control
A provider in Guangxi used voice control skills in telephone

counseling, while Mr. Zhuang in Shanghai used language
skills in order to reduce callers’ stress. “You are 100 percent
HIV negative,” he said sometimes, although most providers
tried to avoid using definite terms when talking about
transmission probability, according to the principles of
HIV/AIDS counseling. However, some providers indirectly
mentioned that their colleagues were not patient in emotional
control or were conducting counseling in a hurry. There were
a few hoax calls in Shanghai, but not in Guangxi.
• Ending the conversation
When callers’ needs had been served, it was time to end the
calls. Before that, some providers would ask whether callers
had any other questions or if they were satisfied with their
service. Usually providers did not end the calls first.
Discussion
Filling the multiple needs of callers with a single medical

profession
Internationally, psychologists, professional counselors, and

social workers, together with medical or health workers, play
an important role in providing hotline services (Arase, 1994;
Ardphoonand, 2000; Kohno et al., 1994; Sukanya & Lawrence,

1993). Two other important characteristics of hotline providers
concern peer counselors, such as gay or female sex worker
counselors (Anthonsen, Kristensen, & Madsen, 1993; M. J.
De et al., 1993; Nalbandian & Levine, 1996; Palmer, 1989) and
volunteers who are recruited from communities or universities
and trained for the hotlines (Gotoh, Yashiki, Kohno, & Hata,
1994; Lagunes-Gaitan et al., 1992; Rigotti et al., 1992). However,
all providers in this study came from the biomedical field,
without strong, professional counseling training and without
the support of peer counselors and volunteers. It may be
argued that providers in the United States CDC’s National
AIDS Hotline are not psychologists either (Scott, Jorgensen, &
Suarez, 1998). The point is that in the United States there are
another 100 hotlines providing voluntary AIDS services (The
development and early uses of help / hotlines, 1991) and it
is easy for people living with HIV/AIDS to use psychosocial
services. This is not the case in China; in general, hotline
providers have backgrounds in the biomedical profession,
so no matter how many hotlines presently exist, psychosocial
needs cannot be adequately met. In this study, more than
half of the callers asked questions related to psychosocial
issues and, as a biased sample of related high-risk groups
and people living with HIV/AIDS, the callers who used the
hotlines displayed significantly more psychological problems
than the general population. Therefore, it was very difficult
for most providers to be competent in responding to all the
psychosocial problems associated with HIV/AIDS. They were
forced to fill multiple needs of callers using only their single,
medical-profession training.
Functions of the hotlines
According to the World Health Organization (1990), the

major functions of HIV/AIDS counseling are prevention and
support. Preventative functions in this study were well served
in the hotlines because the providers’ knowledge structure
was more suitable for preventative services than for crisis
counseling. The average of eight minutes per call in this study,
similar to call duration in the CDC, National AIDS Hotline
(Herrell, 1994), also suggested that the calls were geared
toward basic preventative functions. Supporting functions
in this study referred to psychosocial support. In terms of
referral guidance and information support, many providers
were not able to give callers telephone numbers and addresses
other than that of their own services. The most difficult part
of providing support functions was crisis counseling, when
callers were in need of help in coping with crises. Most
providers acknowledged that psychological counseling was
difficult for them to conduct and some providers felt very tired
of being unable to skillfully explore callers’ problems or of
“repeating” the same answers. Evidence in this study indicates
an inevitable “burnout” among providers. It is also noted that
work-related stress due to the bulk of calls being received by
the AIDS hotline caused burnout among volunteer counselors
in Brazil (O. De, 1992). According to the First European AIDS
Hotline Conference, hotlines should include all workers in the
decision-making process in order to avoid burnout (NCAB,
1989). It is necessary to prevent provider burnout in order to

strengthen hotline supporting functions.
Psychological patterns of current hotline callers
Certain psychological patterns of current callers were
identified from this study. They included HIV-hypochondriac
syndrome, calling on behalf of “friends” as an excuse for
themselves, expressing a preference for specific providers,
using euphemisms for visiting prostitutes, and introducing
personal concerns by beginning with a general-knowledge
question. Among these patterns, the first was the most
interesting.
When a number of criteria had been met, a psychological
pattern was identified as HIV-hypochondriac syndrome. In
fact, the providers in this study tried to identify this type
of caller from many perspectives. From a psychological
perspective, these callers were seen as having “a psychological
knot” in terms of Western ideology, and “having problems”
in terms of local cultural meanings. In Chinese, the
words “having problems” are sometimes used to hint at
psychological or psychiatric problems. According to Kleinman
(1986), somatization and neurasthenia are a more acceptable
expression of psychological discomfort to both Chinese
patients and society because it avoids the special stigma of
mental illness while opening up traditional Chinese values.
However, the callers’ symptoms could not be explained by
somatization and neurasthenia only. From the biomedical
perspective, because some callers in Shanghai showed certain
“forced symptoms” and finally experienced a psychological
breakdown, they were diagnosed as having “neurosis” or
“STD/AIDS-phobic syndrome,” although not every provider

agreed on this diagnosis.
In this study, these callers were not labeled as people
having STD/AIDS-phobic syndrome but rather HIV-
hypochondriac syndrome because of certain features that
distinguished it from the former. First of all, at the HIV/
AIDS hotlines, the psychological pattern of these callers
was unique, and it was impossible to find the same pattern
in callers to the STD hotlines. Secondly, the severity of STDs
and AIDS is completely different, which indicates a difference
in the nature of callers to different hotlines. This argument
was supported by providers who had both STD and AIDS
hotline experiences. Thirdly, the differences in represented
frequencies of callers with STD/AIDS-phobic syndrome
and with HIV-hypochondriac syndrome need further study.
The former in Beijing accounted for 30 percent of the callers
(Zhao et al., 2001), while the latter accounted for less than
10 percent (13/132) in this study. In short, the observed
differences in frequency and severity between STD/AIDS-
phobic syndrome and HIV-hypochondriac syndrome may
be due to the differences associated with the prevalence rates
and the natures of phobia related to STDs and HIV/AIDS.
Finally, STD/AIDS-phobic syndrome may be too general
a term. When unique types of callers are generalized or
subsumed under a general term, it is difficult to identify their
patterns and to develop interventions specifically for them.
Importantly, hotline providers are clearly in need of learning
specific skills, rather than merely being able to express a
general concern, as they have been trained.
Counseling techniques used by providers
In terms of orientation, some providers put themselves in the

callers’ position when they listened to the callers. However, it
cannot be concluded from this study that they were able to use
client-centered orientation to its full potential. Rogers (1987)
states, “Client-centered counseling, if it is to be effective, must
be genuine.” Some providers were genuine and kind to their
callers, no matter how busy they were. Others, however, lost
their “client-centered counseling” perspective and perhaps
changed to a “provider-centered service” perspective when
they were busy, tired, or in a bad mood. According to Mearns
and Thorne (1988), there is a set of beliefs built into client-
centered counseling and one of these is that every individual
has internal positive resources for growth. In this study, none
of the providers mentioned or applied this theory during their
hotline services; neither did anyone mention other orientations.
As Rosenfield (1997) points out, “Indeed many helplines
operate along person-centered lines, whether the service is
one of the minority offering counseling or one of the majority
offering counseling skills.” Therefore, it can be concluded that
the studied hotlines operated along client-centered lines due
to the philosophy of the hotlines. Although providers did not
use client-centered orientation, they used the client-centered
perspective partly based on their short-term training or natural
tendencies.
According to Rosenfield (1997) and Fletcher (1998),
there are certain counseling skills necessary for telephone

counseling, such as starting skills and extra listening skills,
including dealing with silence. In the study, few providers
mentioned these skills. Some providers demonstrated their
control skills or exploring skills well, while others failed to
do so in certain aspects. Why did their short-term training in
HIV/AIDS counseling not lead to more appropriate practices?
First, we should realize that psychological counseling requires
highly professional skills. Thus short-term training might not
be sufficient for nonprofessional staff. Secondly, according to
some of the providers, the courses and content of their short-
term training were not suitable for the Chinese HIV/AIDS
situation and socio-cultural context. Thirdly, even though
not every person was suited to be a psychological counselor,
staff of the HIV/AIDS centers could automatically become
telephone counselors as part of their job responsibilities after
a short period of training. According to Bobevski, Holgate,
and McLennan (1997), the most helpful telephone counselors
are those who are more verbally active, take the initiative to
structure the interview, systematically explore all aspects of
the problem, and address practical and emotional concerns
of the callers. Overall, the more effective counselors altered
the callers’ perspective on their circumstances. Therefore,
effective training of suitable persons should be taken into
consideration in the future.
Recommendations
Establishment of a toll-free psychosocial-based national

AIDS hotline
One of the main findings of this study revealed that common

concerns of callers revolved around psychosocial issues,
especially crisis coping. It is expected that an increasing
number of calls concerning psychosocial problems will arise
as the epidemic progresses. However, local providers were
not able to provide professional counseling to serve those
needs. Because of the limited numbers of psychologists and
professional counselors, it might be difficult to set up local
HIV/AIDS hotlines for crisis counseling. However, it is
possible to set up a toll-free national AIDS hotline for crisis
counseling. Importantly, this should be a psychological or
psychosocial hotline, not a preventive or informational one,
since, according to the findings, the existing local hotlines
already fulfill these preventive functions. The purpose of
setting up a toll-free hotline is also to make long-distance calls
convenient, because most Chinese HIV/AIDS patients live in
the rural areas at present (Q. L. Zheng, 2001). If the hotline
number begins with “800,” it may be more recognizable
to ordinary Chinese as a toll-free hotline. According to
experiences from abroad, providers should include mainly
psychologists, professional counselors and social workers to
help meet the psychosocial needs of callers effectively and
professionally. Based on the lessons in this study, it is also

important that the providers should be full-time staff.
Strengthening psychosocial support functions of local
hotlines
Although it is difficult for every province to set up a new

psychosocially-based hotline, there is clearly a need for
a mechanism for strengthening the psychosocial support
functions of existing hotlines. Ways of strengthening this may
vary from place to place. Some areas can set up a new hotline
by means of non-governmental organizations, while other
areas may reinforce the psychosocial functions of the hotlines
with the help of psychologists, professional counselors,
sociologists, or volunteers. One possibility is to invite and
encourage psychologists and professional counselors to
provide crisis counseling and psychosocial support regularly
on the hotlines. Ideally, this would require the cooperation of
and coordination with local AIDS committees. These methods
of strengthening the psychosocial functions of hotlines may
also be integrated into the local AIDS control movement.
Improvement of hotline operation to prevent burnout
According to the findings related to callers provider

preferences and provider burnout, services would be
improved if hotline operation were improved. First, a
computerized tape-recording system should be built into
the hotline service system in order to enable callers with
special needs to select providers by gender, age, or profession.
Secondly, a burnout support group is needed and regular
meetings are suggested to provide a forum for providers

to exchange ideas about psychological patterns and crisis
counseling and to share their experiences and skills. This may
help to build providers’ confidence and prevent burnout. It is
also important for psychologists and professional counselors
to join these meetings to analyze and explore providers’
problems in terms of professional issues, then allow providers
to share their experiences and gradually improve their skills.
Thirdly, hotlines should explore a more effective way to re-
assign their staff so that only those who are suitable to be
telephone counselors are assigned to positions as hotline
service providers. High-demand times should also be taken
into account so that more providers can be made available at
those times. Finally, hotlines should prepare relevant referral
resources, especially telephone numbers and addresses,
printed clearly on a board or in a manual, to which providers
can refer, in order to better provide referrals.
A new training module in HIV/AIDS telephone counseling
Based on the findings, we can see that even though most

providers had received short-term training, it was still difficult
for some of them to deal effectively with psychological crises.
This was, in part, due to the fact that the training modules and
contents were not suitable for the particular Chinese socio-
cultural context of HIV/AIDS telephone counseling, and, in
part, due to the providers’ lack of a professional counseling
background. Therefore, a new training module with revised
content is essential. It should reflect HIV/AIDS psychosocial
problems as encountered in practice and focus on common
questions of calls, psychosocial patterns of current hotline

callers, and effective coping skills. Western models and
techniques should be modified to match the Chinese socio-
cultural context. In this way, trainees can better understand
the Chinese HIV/AIDS reality, especially in relation to
telephone counseling. To establish the new module, it is
necessary to examine the content and quality of previous
training materials and discuss this issue with the trainers,
who may be helpful in assessing and providing information
from the lessons learned in previous trainings.
Outreach program to IDUs, CSWs and adolescents
As noted, only a few IDUs, CSWs (commercial sex workers),

and adolescents used the hotline services, perhaps because
the hotline agencies did not actively promote their services
in the past. Therefore, the hotlines should extend their
outreach program to them through other channels such as
health education and psychosocial support. There is a need
for hotlines to strengthen their services to these groups of
people in order to compensate for the weaknesses associated
with hotline coverage.
Macro-management of the HIV/AIDS-related hotlines
In this study, the macro-management of HIV/AIDS-related

hotlines in China were found to be inadequate. In order to
encourage and strengthen the psychosocial functions of these
hotlines, macro-management also needs to be improved.
Recommendations for Future Research
It is important for further research to involve psychologists

and professional counselors in the study of HIV/AIDS
telephone counseling. Although this study was reviewed
with the input of social scientists, the research may still have
come up short of its goal of exploring the counseling process
and professional techniques because of the researcher ’s
limited knowledge in psychological counseling. Therefore,
the findings and conclusions of this study may be limited
from a professional counseling perspective. Encouraging the
involvement of psychologists and professional counselors will
help to overcome this limitation and make future studies more
legitimate and representative of the HIV/AIDS telephone
counseling perspective.
Other suggestions for future studies are related to
technical issues. Future studies should allow for a longer
period to record calls, so that the data will be more valid.
Also perhaps a telephone tape recorder could be used to
record the counseling process taking place between providers
and callers, taking into consideration ethical issues. These
types of improvements will be helpful for a better analysis of
HIV/AIDS telephone counseling and thus will help to better
address the needs of the caller population in China.
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Homosexuality
and AIDS
in Mainland
China
Homosexuality and AIDS
in Mainland China
Zhang Beichuan
Introduction
Human civilization enjoys a history of about 5000 to 6000

years but the history of sexology began merely 100 years
ago. In 1920, “homosexuality” was translated into Chinese
as “love between people of the same gender” and only
recently have Chinese scholars begun to turn their attention
to homosexuality, namely, in 1989, after China identified in
1989 its first case of HIV infection contracted by homosexual
contact (China Ministry of Health and UN AIDS Panel, 1997,
pp. 11-12). Homosexual men and people with HIV/AIDS
are marginalized by China’s mainstream culture. Marginal,
however, often means progressive. As society is constantly
changing and far from ideal, it is helpful to identify the
limitations of the current Chinese sex culture and encourage
the development of progressive-minded individuals within
Chinese society.
Economic and Cultural Factors affecting

Homosexuality and AIDS in China
For most of the twentieth century, China relied upon a

small-scale, peasant economy, and later, a planned economy.
Under these economies, living standards were low and
individual sexual needs, both psychological and physical,
were constrained by the idea that human reproduction was
a guarantee of material production.
The advent of a market economy in the late twentieth
century liberated productivity and the thoughts of the Chinese
people. It brought about an expansion of civil society and
made possible the formation of a homosexual community
sub-culture. Further development of the market economy
and rising standards of living for the general population are
expected to help promote the homosexual community.
In place for over 2000 years, the lasting influence
of a small-scale, peasant economy means China’s sex
culture traditionally places the highest value on filial piety.
Stable marriage and procreation are valued, while sexual
activities outside the relationship of a marriage are strongly
disapproved. Non-reproductive sexual activity is condemned
as most dishonorable behavior. These long-standing cultural
concepts are some of the major reasons why homosexuals face
discrimination in China today.
During the 1950s to 1980s, feudalistic asceticism merged
with the rising conservative left-wing. This combination led
to severe discrimination against sexual activities outside of
marital relationships, including homosexual activities. In
Homosexuality and AIDS in Mainland China
this context, same-gender sexual relationships lacked social

support, moral acceptance, and protection under the law.
Nevertheless, sparked by great economic and cultural
reform, the twentieth century also saw the inception of
China’s sex culture revolution. Women’s liberation and
greater freedoms in love, marriage, divorce, and remarriage
were gradually realized. These were followed by movements
for freedoms of non-reproductive sex, bachelorhood, single-
elderly cohabitation, and reselecting gender (changing
anatomic gender), which became partially accepted.
Today in China, homosexuals tend to migrate to cities
which are more tolerant of cultural and economic changes.
This trend has accelerated the AIDS epidemic among
homosexual men.
Methodology
The first phase of this study was conducted during the period
between 1994 to 1998 and investigated homosexual males and
their familiars. Author-subject relationships of confidence
were established. Following this, four surveys on AIDS
and homosexuality in China were conducted in 1998 (435
respondents), 1999 (729 respondents), 2000 (857 respondents)
and 2001 (1109 respondents).
Questionnaires were designed taking into consideration
Chinese culture and the opinions of selected homosexual
males. The survey was first tested before the formal
questionnaires were distributed. The questionnaires were
completed either anonymously in written form or during
face-to-face interviews, and all data was analyzed using the

Statistical Package for the Social Sciences (SPSS).
Demographic variables examined during the surveys
included: age, education level, profession, marital status,
location, sexual orientation, source of sexual attraction,
current and previous homosexual lovers, open disclosure
of homosexual orientation, negative experiences related to
homosexual orientation, etc. In addition, the AIDS-related,
high-risk behavior variables examined included: number of
male sex partners, number of casual sex partners, frequency
of unprotected anal intercourse, frequency of homosexual
group sex, frequency of lack of condom use, frequency of STD
incidence, and other variables.
Findings
Cultural and economic influences on homosexuals in China
In the samples with homosexual males, the average age was 30

years old. Sixty percent had graduated from college and had
white-collar jobs in large or middle-sized cities. Eighty percent
had married or planned to marry, 33 percent had actually
married and only 40 percent of those unmarried had decided
not to marry. Due to the fact that 64 percent of the people in
China live in agricultural areas, which were not included in
this study, it was estimated that those who were married or
planned to marry actually accounted for over 90 percent or
more of the total homosexual male population.
Ninety percent had entertained or were continuing to
entertain a hope of forming a same-gender family resembling
a common heterosexual family. More than 60 percent had a

child or planned to have a child. Seventy percent attributed
their failure to form a stable sexual relationship with a man
to discrimination. Thirty-three percent had experienced
abuses such as insult, extortion, beating, same-gender sexual
harassment, and rape. About 17 percent had experienced
abuses in the past year. Discrimination had caused 9 to13
percent of the respondents to attempt suicide, among which
about 33 percent had experienced a serious suicide attempt.
Homosexual male intercourse
In the 2001 survey of 1109 homosexual male subjects, the

average age of respondents was 33 years old. Fifty-six percent
had graduated from college, 86 percent had white-collar
jobs, and 75 percent lived in large or middle-sized cities. The
average number of accumulated sex partners was 33. The
average number of sex partners within the previous year
was 6 and over 25 percent had more than five sex partners.
In the previous year, more than 80 percent had experienced
unprotected oral sex, 67 percent had experienced unprotected
anal intercourse, nearly 50 percent had experienced a one-night
stand (where the sexual partner was a stranger), 40 percent
had visited other places where they had sexual intercourse
with males, nearly 20 percent had participated in group sex, 8
percent had bought sex, 3 percent had sold sex, 6 percent had
performed fist intercourse as the dominant partner, 7 percent
had received fist intercourse as the passive partner, and nearly
3 percent had experienced sadism (involving bleeding) and
masochism.
Heterosexual intercourse
In the same survey, questions regarding heterosexual

intercourse were asked to the 1109 homosexual male subjects.
Fifty percent had experienced heterosexual intercourse, with
the average number of female sex partners being two. Thirty-
three percent of the homosexual men were married. In the past
year, 66 percent of the homosexual men who were married
had experienced sexual intercourse with their spouses.
Homosexuality and AIDS
Three national surveys regarding homosexuality and AIDS

were conducted in China–in 1999, 2000, and 2001. The
number of provinces in which homosexuals reported that
they knew homosexual men infected with HIV/AIDS were
23 provinces (1999), 27 provinces (2000), and 29 provinces
(2001). The annual surveys conducted during the period of
1998 to 2001 revealed that self-reported HIV infection rates
were 2.5 percent (1998), 17.7 percent (1999), 4.2 percent (2000),
and 5.4 percent (2001) (Zhang, Liu, Li, & Hu, 2001a; Zhang,
Li, & Shi, 2002).
Discussion
Resolving issues of homosexuality in China
According to the 2001 China Bulletin for Population Statistics

and other local and international reports (Li, 1998; Michael,
Gagnon, Laumann, & Kolata, 1994; Zhang et al., 2002), among
people aged over 14 years in China, there are 27 million male

and female homosexuals (including bisexuals). Of these, 17.8
million are male homosexuals and 8 million live in the cities
as residents or migrants–the main subgroup of AIDS sufferers.
It is estimated that 10-15 percent of adult males in China have
experienced same-gender sex (Zhang et al., 2002), and some
homosexuals play a part in transmitting HIV to women or
other subgroups of male homosexuals.
Controlling the AIDS epidemic among homosexual men
plays an important part in controlling the AIDS epidemic in
urban areas. Therefore, resolution of the challenging issues
relating to homosexuality in China is vital. The physical and
psychological health, lives, and occupational development
of 127 million people–27 million homosexuals along with
their close family members who number about 100 million
(Zhang, 2000; Zhang et al., 2001b, pp. 7-10)- depend on this
resolution. It would have a positive effect on family harmony
and social stability.
Homosexuality and AIDS awareness among the Chinese

public
Among the Chinese public, very few people, including

educated individuals, are aware that lesbian intercourse
seldom (far less than heterosexual intercourse) spreads
HIV. People are also largely unaware that homosexuals can
and many do have faithful and stable relationships, akin to
heterosexual relationships. Many people also do not realize
that some common sexual practices among homosexuals,
such as oral sex, are also common among heterosexuals,

and that anal sex is also practiced by 23 percent of women
in China. The main difference in sexual practices between
homosexuals and heterosexuals lies in the more frequent
anal, oral and fist intercourse among homosexuals (Lu, Pan,
Chen, 1992). Because of the lack of knowledge of the Chinese
public regarding homosexual relationships, the homosexual
community is in a disadvantaged and high-risk position.
Recommendations
In order to find a resolution to the issues of homosexuality,

multidisciplinary participation is necessary. This requires
the full input and cooperation of the medical community
(including experts involved with AIDS, STDs, sexual health,
health education and clinical psychology/psychiatry), the
social science community (including experts of sociology,
bioethics, women’s studies, law, and human rights studies),
the public media and, in particular, the driving force of the
homosexual community. In controlling the AIDS epidemic,
the gay community should play a central role.
An illustration of such a multidisciplinary cooperation
is a health education program called Friends, initiated by the
author in 1998 and sponsored by the Sexual Health Center
of the Affiliated Hospital of the Medical College at Qingdao
University in China. This program conducts health, AIDS,
and safe-sex educational services and interventions, as well
as research activities. It is guided by gay volunteers and
academic specialists from over ten disciplines. The main
work of the program is compiling and distributing a bi-

monthly educational magazine entitled Exchange of Friends,
of which 28 issues have been published since 1998. The five
sections within the magazine outline homosexual-targeted
AIDS interventions, scientific knowledge on homosexuality,
personal memories and experiences of Chinese homosexuals,
homosexuality-related news and information from China
and abroad, and help for homosexuals to find friends. The
program primarily serves gays, the scientific community, and
the mass media. It is currently the main source for information
on homosexuality in China and has been endorsed by AIDS
NGOs and Chinese health authorities since 1999.
At a 1999 high-level strategy symposium on AIDS
control, suggestions and strategies for reaching gay men were
offered by the author, on behalf of the Exchange of Friends work
group, and these suggestions were endorsed by symposium
attendants. In 2000, after a seven-year ban, the author’s
research reports were finally approved for publication (Zhang,
2000). Currently, homosexual volunteers and doctors in 36
cities help distribute the Exchange of Friends publication in gay
venues. Ten thousand copies of each issue are now published
and distributed. The scientific information and humanistic
perspectives toward gays which are published in Exchange
of Friends are frequently cited by the mass media. Exchange
of Friends has contributed to increasing recognition and
tolerance of homosexuality in China, improving homosexuals’
living situations, and providing psychological help to
homosexuals.
A 2001 survey of 300 homosexual men living in a

municipality directly under the central government revealed
that 49 percent of the respondents had read Exchange of
Friends and that 90 percent had enjoyed reading it and
wanted to read it in the future (Li, 1998, pp. 344-349; Zhang
et al, 2002). For those who had undergone health education
intervention offered by the program, more than 90 percent
believed the program was conducive to psychological
health, quality of life, social adaptability, self confidence, and
resistance to discrimination. Eighty percent believed that
the program relieved them of the psychological pressure of
discrimination and believed that the program was helpful to
their occupational quality of life. Eighty percent of those who
had attempted suicide dismissed or diminished their thoughts
of suicide. Only 20 percent still wanted to enter into marriage
with women. More than 90 percent reported becoming more
vigilant about AIDS, while only 10 percent continued to have
many sex partners. Seventy percent discontinued or decreased
their frequency of sexual intercourse with strangers. Of those
who had experienced anal intercourse, more than 60 percent
stopped or decreased their frequency of anal intercourse and
more than 50 percent of those who continued to engage in
anal intercourse reported more frequent condom use. Twenty-
five percent of those who had experienced oral intercourse
reported more frequent condom use when they had oral
intercourse. Nearly 50 percent increased their frequency of
non-penetrative intercourse and nearly 30 percent changed to
only having non-penetrative intercourse (Zhang et al., 2001a;
Zhang et al., 1993).
Exchange of Friends has also assisted ten cities in setting

up help hotlines serving homosexuals, four of which are being
aided by health authorities. It is the most influential program
on homosexuality in China today
Challenges and Prospects in China
A major challenge to resolving homosexual issues in China

lies in the scarcity of political support, resources and network
support. In order to overcome this challenge, education of the
public is needed and the first step in this direction is educating
those who educate the public, namely, scholars. At present, the
homosexual community is constrained by poor scholarship
and weak power. Therefore in a difficult position to drive
social progress in recognizing issues related to homosexuality
and AIDS.
The challenges regarding traditional scholarship need
to be overcome. Firstly, scholars need to recognize that
differences among individuals, including differences in sexual
orientation, are natural and normal; it is uniformity that is
unnatural and abnormal.
Secondly, scholars need to study and discuss the issues
relating to homosexuality and AIDS with an attitude of
egalitarianism and objectivity, from the perspective of politics
and human rights. They must realize that protection of the
human rights of homosexuals is protection of the interests of
the public. The benefits of mutual education between scholars
and homosexuals to promote an AIDS-aware community must
be appreciated.
China has proposed that by 2010 it will have limited its

accumulated HIV cases to 1.5 million cases (Public Health
Department of China Health Ministry, 2002, pp. 12, 27).
However, considering the trend of the AIDS epidemic in
recent years, the number of HIV cases in China will reach that
figure sometime during 2003 to 2004. UNAIDS publicized that
in 2001 the number of HIV cases had reached 1.5 million in
China (State Council, 2002, pp. 9-10) and data from China’s
authorities estimated that as of June 2002, the number of
cases had reached 1 million (United Nations Theme Group
on HIV/AIDS in China, 2002, pp. 11-12). Sexual activity is
increasingly seen as the main route of AIDS transmission
in China and AIDS concerns people of all different sexual
orientations. By focusing on AIDS control as a foundation
approach and using moderate methods, it will be possible to
address homosexuality issues in China today.
Acknowledgement:
Special thanks to The Ford Foundation and the Barry-Martin Trust for their
support.
References
China Ministry of Health and United Nations AIDS Panel. (1997).

Challenging AIDS, actuality and need: AIDS in China. Beijing: China
Ministry of Health.
Li, Y. (1998). Subculture of homosexuality. Beijing: China Today Press.
Lu, L., Pan, A., Chen, J. (1992). A clinical analysis on one thousand
homosexuals. Chinese Mental Health Journal, 3(6), 132-134.
Michael, R. T., Gagnon, J. H., Laumann, E. O., & Kolata, G. (1994). Sex in
America. New York, CSG Enterprise.
Public Health Department of China Health Ministry. (2002). Four obstructions
restrict the control of AIDS in China. Beijing: Public Health Department
of China Health Ministry.
State Council. (1998). The plans to prevent and control AIDS for middle and
long periods, China (1998-2010). Beijing: State Council.
United Nations Theme Group on HIV/AIDS in China. (2002). HIV/AIDS:
China’s titanic peril, 2001 update of the AIDS situation and needs
assessment report. Beijing: UN Theme Group on HIV/AIDS in China,
UNAIDS China Office.
Zhang, B., Li, X., Hu, T. (1993). Friend: A program of control on AIDS among
MSM. China Health Education, 9(4), 9-16.
Zhang, B. (2000). Homosexual men and AIDS epidemic. Journal for China
STD AIDS Prevention and Control, 2(6), 126-27.
Zhang, B., Liu, D., Li, X., & Hu, T. (2001a). AIDS-related high-risk behaviors
and affection factors of men who have Sex with men (MSM) in
mainland China. Chinese Journal of Sexually Transmitted Infections,
1(1), 7-16.
Zhang, B., Liu, D., Li, X., & Hu, T. (2001b). Study on HIV/AIDS high risk
behavior and its factors among men who have sex with men in China.
Journal for China STD/AIDS Prevention and Control, 1(7), 7-10.
Zhang, B., Li, X., Shi, T., et al. (2002). A preliminary estimate to population
size and HIV infection rate among male homosexuals/bisexuals
in China. Journal for China STD/AIDS Prevention and Control, 4(8),
197-199.

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Contents

Foreword ............................................................................................. vii

2. Representations of Gender and Sexual Identity in Research

3. Gender and Sexual Health of Adolescent Females

4. Sexual Behavior of Young Out-of-School Males

5. Sexual Behavior of Street Gangs in Davao City, Philippines

6. Providing Contraceptive Services to Unmarried Youth

7. HIV/AIDS Telephone Counseling

8. Homosexuality and AIDS in Mainland China

This publication on Researching Sexuality and Sexual Health

identities, such as “good-bad,” “modern-conservative,” etc.

These peer networks may not be entirely positive, with

evaluates the effectiveness of health service providers in

and initiating a health education program called “Friends” in

A short methodological note will be useful here, given that

I would say narratives aren’t “done”; instead, they

depend on using an outline or a guide with specific topics to

Tonio, a Taxi Driver

the long working-hours that he had to put in. “Alanganin

that he would occasionally have sex with the sex workers in

I finally asked him if he had ever had any sexually

disease. But to cushion the blow, he never admitted that he

Let me move now to the second narrative, this time gathered

One of our research subjects was Veronica, aged 24 years

of children), followed by a question about whether she was

Veronica repeated that she didn’t want to get pregnant, even

What Do Narratives Have to Offer?

In sharing these two narratives I had hoped to show what

potentials in eliciting narratives, I would first ask: What might

As an anthropologist, I have found narratives to be

A bakla is preferable because he can’t get pregnant.”

that the statistics generated in surveys are exact reflections

I finally asked the student where the anthropology was, in

The Theoretical Lens

This paper focuses on a particular theoretical framework for

and reinforce knowledge about the world. Two types of

a person and his/her subjectivity, such as by making gendered

discourses interaction of knowledge about

a person’s gender and

The analytical framework above is explained by drawing

the research question: “What is it like to be a woman in the

Interpretation and Discussion of Data

Case 1. Negotiating premarital sex (a 21-year-old woman)

improper for fiancés to kiss and hug one another.

authoritative discourses regarding marriage and romance

It would depend on the circumstances. If we

According to this excerpt, this young woman would allow a

Case 2. Negotiating sexual and asexual self (a 27-year-old

want to try them with their wife. If a wife refuses to cooperate, a

In light of the AIDS crisis and the country’s nationwide

embracing their husbands, knowing that this gesture would

In Thailand, long-standing institutionalized or

Discourse Analysis and Challenges in Researching

Discourse theory is useful in analyzing Thai women’s

It also helps uncover women’s consciousness and desire to

them spawns a tension that women feel. Ambivalence and

There is increasing evidence in Thailand of changing sexual

for young males; men are expected to have a strong sexual

in compromising safe premarital sexual behaviors among Thai

Thailand’s population of 60 million is spread over four

in Chiang Mai, the northern regional capital, and Lamphun, a

students were sexually experienced (Nuchanart, 1988). Studies

to marry. Condom use for sexual debut ranged from 20 percent