High risks of HIV infection have led to dramatic changes in patterns of early sexual experience among young Thai men. We know little about the shifts in attitudes and expectations underlying these changes in behavior.
In-depth interviews with 10 young men are used to explore recent changes in the social context of male heterosexual relations in Thailand. Changes in ideas about the appropriateness and availability of commercial and noncommercial sexual relationships are examined, as well as changes in ideas regarding the importance of condom use during various types of sexual encounters. The use of standard interview guidelines and the systematic coding and analysis of transcripts allows comparison of these issues across cases.
In large part because of fears about AIDS, at least some younger Thai men are rebuffing older friends' efforts to initiate them into traditional patterns of sexual life, patterns that emphasize heavy alcohol consumption followed by a group visit to a brothel. Some participants report that opportunities exist for sexual relationships with female peers; these opportunities appear to be leading men and women to reevaluate longstanding patterns of male sexual expression.
The changing context of men's early sexual behavior should be considered when developing programs to prevent commercial sex patronage and to reduce the spread of HIV and other sexually transmitted diseases through noncommercial or quasicommercial sexual relationships.
International Family Planning Perspectives, 2002, 28(1):
After having suffered the impact of a rapidly expanding AIDS epidemic for almost a decade, Thailand has in the past few years seen remarkable declines in the rates of spread of HIV and other sexually transmitted diseases (STDs). A series of studies measuring infection levels among several populations, especially military recruits, have documented changes in the incidence of HIV infection. It is widely assumed that behavioral change is also occurring, but there have been fewer systematic efforts (especially using individual-level data) to assess how behavioral change is affecting the spread of HIV and vice-versa.* It is also widely assumed that the normative and attitudinal structure underlying patterns of heterosexual behavior are changing dramatically, but there is very little research of any kind on the extent or nature of these changes.
Qualitative methods provide an ideal approach for exploring the changing social context in which early Thai male sexual behavior occurs. The open-ended format of this approach allows for extensive rapport to build during the interviews and provides opportunities to explore complex, ambiguous and potentially sensitive material. In this article, we used in-depth qualitative interviews to shed light on the normative and attitudinal shift underlying these recent epidemiological and behavioral changes. A secondary goal is to highlight potential topics for a longitudinal, nationally representative survey of Thai sexual behavior.
Historical and Cultural Context
Systematic surveys beginning in the early 1990s indicate widespread commercial sex patronage among young, unmarried Thai men, a peer group context for these behaviors and associated heavy alcohol consumption.1 Given the high prevalence of STDs during the two decades prior to these surveys,2 these patterns were surely widespread long before the surveys were conducted.3
Because of the lack of reliable data, it is difficult to make confident generalizations about patterns of sexual behavior occurring before the advent of modern social science surveys. Nevertheless, it seems virtually certain that commercial sex was readily available in most urban areas for men who had the discretionary income to pay for it. Still, it was not until the widespread modernization of the Thai economy during the 1960s that large numbers of Thai men had the discretionary funds required for regular visits to commercial sex workers. Declining fertility and the increasing importance of income generation for women,4 the influx of money and foreigners associated with the war in Vietnam and the expansion of international tourism5 all may have provided further impetus to the spread of commercial sex in Thailand.
Confident generalizations regarding predominant sexual norms and attitudes—like those for sexual behavior—are not possible for the period prior to the early 1990s because there were no systematic studies of this topic. Frequent references to sexual relations (both commercial and noncommercial forms) outside of marriage throughout Thai literature6 belie the claims of those who would argue that Thai sexual morality has been fundamentally corrupted by outside influences;7 sexual license for Thai men is long standing and well established. Even so, it is critical to distinguish among the levels of acceptance for different forms of sexual expression. Well-to-do married men's relationships with mistresses are considered by many to be their prerogative, even if such extramarital relationships can be quite disruptive to both the marriage and the community at large.8 Until recently, unmarried men's commercial sex participation has probably been considered by most in Thailand to be quite ordinary behavior. In contrast, at least one study has found that during the 1960s, noncommercial premarital sexual relations between unmarried men and women were generally frowned upon in the rural areas where the research was done,9 a finding likely generalizable to other rural areas of the country at that time.
How pervasive these early sexual patterns and their associated attitudes were is unknown. By the early 1990s, however, researchers using modern survey methods had documented marked variations in attitudes, norms and behaviors regarding commercial sex; for example, the most privileged groups participated less in commercial sex than did other groups.10 Prior to this period, it seems likely that it was common for both privileged men and the poor to visit commercial sex workers.11 But even if commercial sex patronage was in decline in some sectors of Thai society, norms during the 1990s among many groups of men apparently were quite supportive of it.12
Until quite recently, patronage of commercial sex among Thai men seems to have been generally tolerated, if grudgingly, by Thai women. For unmarried men, it has been viewed as an unremarkable and natural activity in a man's maturation process. Occasional commercial sex patronage among married men, while more problematic, has been generally tolerated by many married Thai women as well.13 This tolerance is rooted in a cultural system that is quite sympathetic toward male sexual desire. While sexual preoccupation and unrestrained sexual behavior are flawed from a Buddhist perspective, it is understood from a Thai Buddhist point of view that sexual desire is a singularly difficult obstacle for men to overcome.14 Even if male philandering has, at least in a philosophical sense, been viewed as a sin and as contrary to Buddhist principles, women generally have—until recently—understood, accepted and tolerated it as an inherent and fundamental male weakness.
Epidemiological and Behavioral Changes
Because of modernization and epidemiological forces, longstanding and widespread permissive sexual norms for men have recently become problematic. The spread of HIV and AIDS is increasing fears among women about the possibilities of infection,15 and with good reason: Sex with one's husband is now the main route of contracting HIV among married Thai women.16
But if epidemiological forces are having a conservative influence on women's sexual attitudes and behavior, modernization is having the opposite effect. Given increasing awareness of the less divergent norms of sexuality for men and women in the west—where there is a less pronounced "double standard"—and less supervision in the cities where many young Thais have migrated for work,17 today's Thai women are more likely to engage in premarital sexual experimentation than those in earlier generations.18
If more women are becoming willing to engage in premarital sexual relations, there may be increasing opportunities for men to have noncommercial premarital sex. Moreover, men's fears of infection by commercial sex workers may be an incentive to seek out noncommercial sexual partners and to engage in other strategies perceived to be less likely to lead to infection. Behavioral and epidemiological research suggests that such changes in men's behavior are occurring. For example, in a 1993 sample of the general young adult population, about one-third of young men reported that their first sexual intercourse was with a commercial sex worker, compared with 71% in a 1991 sample of military recruits from the upper north, and 43% from other areas in the country.19 In addition, 43% of the men in the 1993 study said it was wrong, or a mistake (pen gan kratham pit), for an unmarried man to engage in commercial sex.20 At the same time, HIV and STD infection rates have fallen dramatically.21 Taken together, a conclusion of phenomenal behavioral change seems inescapable.
These changes are occurring in the context of a massive public education campaign about the dangers of unprotected sex with commercial sex workers and a national campaign to enforce a 100% condom use policy among brothel owners.22 Evaluation of the latter campaign indicates a substantial increase in condom use during commercial sex,23 but there has as yet been little attempt to evaluate concurrent changes in men's ideas regarding the propriety, availability and desirability of various types of sexual contacts.
DATA AND METHODS
In December 1996, we recruited and interviewed 10 unmarried men who had different social backgrounds and who had extensive networks with other unmarried men in a provincial town and rural area approximately three hours from Bangkok.
The 10 men were recruited by a Thai research assistant and a Thai researcher through personal contacts at a local village, a construction site, a vocational school and a motorcycle shop. The recruiters asked their contacts to help them identify informants—young men who were typical of the other young unmarried men at the site, had lots of friends and acquaintances and would be willing to talk to us about the prevailing sexual norms and attitudes in their particular social groups. We stressed that what was important to us was not whether the informant himself visited commercial sex establishments frequently, rarely or even at all, but rather that he knew what was going on among his peers.
When we met potential informants, we briefed them on the nature of the study and explained that the interview would be primarily about the leisure activities of their group, including sexual activities, and would focus on current norms and attitudes regarding the sexual activities prevailing among their male friends and associates. We stressed that what was important to us was that they knew what was going on among other men in their social group, and not that they tell us about their own sexual behavior. In practice, many of the men chose to use themselves as examples. We did not record identifying information about the informants. The men we interviewed were aged 18-26 (Table 1), sexually experienced and unmarried. All but one had never been married. (It was not clear whether one man had ever been married.)
Our recruiters and their contacts reported no refusals, but it is likely that they approached individuals whom they thought would be willing to participate. Informants were offered a small sum of money for their time; several refused the gift.
All 10 interviews were conducted in Thai by the lead author, four with the help of a Thai research assistant. The interviewer reviewed the purpose of the study with each informant and received permission to record the interview (there were no refusals at this point). Interviews took place in a secluded, private area. Each interview opened with a few warm-up questions about the informant's work and family, followed by questions about his background and social networks. The interviewer then asked a number of open-ended questions about his impressions of current sexual patterns among his friends and acquaintances, norms and attitudes underlying these patterns and any recent changes that he perceived. These questions emphasized norms regarding commercial sex visitation and condom use, opportunities for noncommercial sex relations and the nature of noncommercial sex relationships.
After five pretest interviews, we finalized a set of guidelines to be followed during the study, so that we would later be able to make systematic comparisons across individuals and their respective social groups. The open-ended nature of the discussions, however, provided considerable leeway for informants to express their views in detail and for the interviewer to explore relevant topics as they arose.
Interviews were recorded, fully transcribed and word processed in the original Thai language and in English translation. We then systematically coded and analyzed the English transcripts using text analysis software.24 We used two coding strategies to classify and evaluate the data. The first was predetermined by the guidelines; transcript segments were classified by the topic being discussed. The second followed an analytic induction approach that classified segments by topics brought up by the informants and not anticipated in the guidelines.25
To assess intercoder reliability, both authors independently coded the first transcript. Differences in their interpretation of the transcripts and codes were discussed and resolved. This process continued with each transcript until intercoder reliability reached at least 90%, and then was discontinued. The first author coded the remaining transcripts.
We used results matrices (grids of results with informants on one axis and topics on the other) to facilitate our analysis.26 When discussing a particular finding, our aim is to convey the degree of consensus, portray the predominant opinion (where there is one), and indicate the distribution of views on the topic. We illustrate particular points using typical exchanges between the interviewer and informant, with "I" indicating that the interviewer is speaking and "R" indicating that the informant is responding.
One clear consensus among our informants is that the sexual milieu has changed dramatically and rapidly over the last few years. These changes involve differences in both the social context and the opportunity structure in which male sexual expression occurs.
Changes in the Types of Partners Available
In contrast with prior survey data that indicate large proportions of unmarried men having their early sexual encounters exclusively with commercial sex workers,27 the men in our study describe a wide array of potential sexual partners for unmarried men. In addition to sex workers, these partners now include serious girlfriends and casual partners, as indicated in the following exchanges:
I: For men who are not sexually experienced, what kind of women are [typically] their first [sex partner]?
R: Well...not good women.
What do you mean "not good women"?
Going to the brothels....It is the prostitute.
—24-year-old rural farmer
I: Nowadays, are there men who haven't had experience, but have sexual need or want to have experience, and don't want to go to prostitutes?
R: Sometimes they prefer their girlfriends, sometimes they do it [first] with their girlfriends.
I: So, they have the opportunity to sleep with their girlfriends?
R: These days, girls are brave. In secondary school, they are together in pairs [with young men].
—22-year-old rural farmer
I: Your friends who are [sexually] experienced; most of them will have experience with women of about what age?
R: Of about the same age. First they might be friends in classes.
—26-year-old urban salesman
Changes in Commercial Sex Patronage
Commercial sex visitation in a peer group context seems to be becoming more rare in Thai society. While survey evidence indicates that there have long been some men who have opted out of premarital commercial sex,28 half of our informants made explicit mention of a decline in commercial sex patronage among their friends:
Three or four years ago, did you know anyone who liked to go to prostitutes, before AIDS became well-known?
R: [Actually], at that time, AIDS was here already, but there were still some who went.
I: If you compare the situation three to four years ago to nowadays, are there any changes?
R: What kinds of changes?
I: About going to prostitutes, about sleeping with women.
R: Mostly they don't go to prostitutes. There is no one asking me to go. No one goes.
—18-year-old urban student
Seven of the men said that they or members of their social group go to prostitutes less than they used to, very little or not at all. These findings support recent survey and STD data29 that suggest massive behavioral change and contrast remarkably with data from the early 1990s, when most men readily professed to habitual commercial sex patronage.
Changes in Ideas About Sexual Initiation
Not only do patterns of commercial sex patronage appear to be in flux, but rationales for and circumstances of this behavior also seem to be changing. Part of the justification underlying early male sexual activity involved the widespread idea that men need to be "trained" for sexual life. In the local idiom, this training is symbolized by the term kun crew (literally, ascend the teacher), which describes the teaching of sex to a young man by a commercial sex worker.30 While this logic still held currency among some informants, it was not widespread: Only two men mentioned it, and another specifically rejected it:
I: If [men] don't go to prostitutes and try to have [sex] with a girlfriend for the first time, what will happen?
R: One has to have experience about it before.
I: If one has no experience, what will happen?
R: They don't know what to do....Because we don't know where the female's [parts] are. We can't find it. We don't know.
—24-year-old rural farmer
I: So your friends are not out trying to gain [sexual] experience with women. But aren't they afraid that they won't know what to do when getting married? What do they think about this?
R: They think it is natural. Anyone can do it.
—18-year-old urban student
Traditionally, men coming of age sexually faced significant peer pressure to participate in commercial sex, and in at least some cases, to forgo condom use while doing so.31 In all significant Thai social relationships, the deference of young people to those who are older is axiomatic.32 In the area of male sexual behavior, older friends or relatives traditionally encouraged and paid for their younger friends to engage in commercial sex when the time was deemed appropriate.33 In this way, men passed on the traditional means of sexual initiation to their younger friends, which no doubt served to maintain (at least for awhile) sexual practices that became extremely dangerous after the advent of AIDS.
These norms appear to be coming under scrutiny in at least some circles, and this basic feature of relations between older and younger (pi-nong) males is apparently being disrupted by the rapidly changing social context. Some of the informants expressed both surprise at and frustration with younger friends who are coming of age in an entirely new social environment.
R: Some [young men] are not brave. They have never passed women before....They are around 16-17 years old. [But they say it is] not their time yet. They are not brave, but we [try to] convince them.
I: If we asked them to go to a prostitute, but they are not ready, what would they say?
R: Mostly they say they have no money, or "low budget."
I: [I've heard that] if someone hasn't enough money, their senior friend may pay for them, especially for those who have no experience with women before.
R: Oh. It used to happen. I used to call women for them, but they wouldn't go....Whatever you do, they just won't go.
—21-year-old urban laborer, rural background
Reasons for Declining Commercial Sex Patronage
Among the informants who said men have reduced their participation in commercial sex, we probed for reasons. As we found in an earlier study on a similar topic,34 the reasons are for the most part practical, rather than moralistic, in nature. In fact, moral themes were notably absent from our discussions—only one informant expressed his group's opposition in such terms:
I: In your group, why don't they go to prostitutes? Are they not interested in it?
R: They don't think it is a good thing. So they aren't interested in it.
I: What does it mean, 'not a good thing'?
R: Going to a prostitute is not good. It is not appropriate for us at our age.
—18-year-old urban student
Practical reasons prevailed. Half of the informants referred to fears about AIDS and other STDs as a reason for the decreasing patronage of commercial sex workers; one cited the expenses involved in going; another cited embarrassment. One informant reported that he seldom went to prostitutes because he knew he would be drinking, and did not trust himself to use condoms if he was drunk:
...for those who have no [sexual] experience, why don't they go to brothels?
R: They don't dare go. Afraid of diseases.
I: Afraid of diseases? What kinds of diseases?
—18-year-old urban student, rural background
R: [I only] go there once in a while, not often, there may be AIDS.
I: Are you afraid?
I'm afraid of getting drunk. If drunk, I feel brave.
I: If you're not drunk, you don't go?
R: If I'm not drunk, then I don't go. If drunk, I feel brave.
I: If you are drunk [and you go], do you use a condom?
R: Sometimes I don't use it because of being drunk. When getting drunk, I'm not thinking of other things. If I'm not drunk, then normally I use a condom.
—21-year-old urban laborer, rural background
This example was the only instance of reported current nonuse of condoms while engaging in commercial sex after drinking. But if this informant represents a segment of the male population who patronize sex workers—a core group of men who will continue to participate in unprotected commercial sex in spite of the risks of doing so35—this behavior has serious implications for these men and for the women with whom they have sexual relations.
In traditional male social relationships, alcohol plays a very important role in the expression of manhood, gives a central focus to a male social circle and provides an alibi for what would otherwise be seen as irresponsible behaviors.36 In the face of widespread, aggressive campaigns to educate men about the dangers of AIDS, it is becoming more and more untenable for men to participate if they are sober. If there is a core group of men who continue to use intoxication as a rationalization for continued participation in unprotected commercial sex, the link between drinking and commercial sex visitation may be extremely difficult to break.
Condom Use with Commercial Sex Workers
In the absence of a state-of-the-art national survey on sexual behavior, it is difficult to know whether the predominant factor in the decline in HIV and other STD infection in Thailand is decreasing commercial sex patronage or increasing condom use among men who continue to visit prostitutes.37 The available evidence, biased as it must be by increasing pressures for both commercial sex workers and their clients to report socially encouraged behaviors, indicates substantial increases in condom use. The number of condoms used has increased, as has reported condom use.38
Our informants reported behavior in their social networks that is consistent with these results. Four reported that men in their networks always use condoms; three said that men they know usually use them. Our informants indicated that condom use with commercial sex workers has increased both because of the success of the national 100% condom use campaign, which makes it more difficult for men to purchase unprotected sex, and because many men are unwilling to engage in unprotected sex in the current epidemiological environment.
I: Compared to 3-4 years ago, do men use condoms more or less now?
R: Now they use them more. In the past, there was not this dreadful disease. It has just appeared recently. When I was young, we didn't use them.
I: Didn't use them at all?
R: No, didn't use them at all; not when I was 15-16. They've only had campaigns about 5-6 years.
I: Do men always use them nowadays?
R: Ah, now if the men don't use condoms, women don't allow them to lie down with them.
I: In your group, is the use of condoms increasing?
I: Has it increased to 100%?
R: Yes. We are afraid as well, not only is it the women who are afraid. We still have a long life in front of us.
—25-year-old urban laborer, rural background
Three informants said that men they know do not use condoms under some circumstances with commercial sex workers. In addition to the issue of intoxication, two informants described special relationships between some clients and commercial sex workers that lead to a lower willingness to use condoms.
R: One-hundred percent of Thai men use condoms [with commercial sex workers], except when they go to brothels and they are the regular customers. Too often [commercial sex workers] allow them not to wear condoms.
—24-year-old urban teacher, rural background
Non-Brothel-Based Commercial Sex
Several informants mentioned an increasing propensity for men to contract for sex in nonbrothel venues, for example in restaurants and nightclubs. Such an adaptation is not surprising, especially for slightly older men who came of age when commercial sex visitation by unmarried men was normative. They may find it more difficult than younger men to completely forgo commercial sex, and may also have the resources necessary to purchase these more expensive forms of commercial sex. Four of the six older informants (aged 22-26) described this shift in behavior. Two typical discussions follow:
I: I would like to ask about your friends' groups or about men you know—if they have free time, might they go to prostitutes, or brothels or massage parlors? Are there many people who do this?
R: Err...[as] for those going to brothels, there [are] none. For those going to entertainment places and meeting women, there are some.
—26-year-old urban salesman
R: Yes. Sometimes we go to prostitutes.
I: Where do they go: restaurants, or brothels or massage parlors or what...?
R: Calling it politely a restaurant...because we can also sit and drink inside it. They open it as a restaurant, but they have women [for hire], too.
—22-year-old rural farmer
Although the above scenarios are clear manifestations of commercial sex, albeit less explicit than in brothels, other types of sexual relationships men mentioned fell less clearly into a commercial sex category. For example, the issue of picking up women for sex (or at least trying to) at pubs and bars came up frequently in our interviews. One man mentioned exchanging money for this type of sex. It is unclear how frequently these types of quasicommercial sexual encounters occur and what kinds of relationships the participants have, but what is clear is that these arrangements are quite distinct from brothel transactions.
Changes in Romantic Relationships
Concurrent with changes in the normative and attitudinal context of commercial (and quasicommercial) sexual relationships, there are changes occurring in noncommercial romantic relationships. These changes are even more difficult to assess, because there are longstanding and fairly strong norms against noncommercial premarital sexual relationships. We know little about them, including how often they occur, especially prior to the surveys of the early 1990s.
Early observers of Thai rural life have noted that noncommercial sexual relationships were not rare;39 however, there were likely fewer opportunities than exist today for men and women to pursue these relationships because of the close supervision afforded by a village setting. Today, young people's migration to Bangkok and other cities has resulted in greater opportunities for them to pursue sexual relationships unsupervised by family and other village members.40 Survey data indicate that among youth, behavior and general attitudes about premarital sexual relations are becoming more liberal.41 Our informants also perceived these changes and attributed them to increasing fears of commercial sex, increasing opportunities for noncommercial sex relations, and changing women's views on men's commercial sex patronage.
• Men's increasing fears of commercial sex. Three men openly cited the avoidance of HIV as one of the advantages of noncommercial sexual relationships. The following exchange is typical:
I: Nowadays and in the past 3-4 years, for men you know, is the chance of having a [sexual] affair with ordinary women increasing or decreasing?
R: It may be increasing, because becoming involved with ordinary women doesn't risk contracting the dreadful disease.
—25-year-old urban laborer, rural background
I: For friends in your group, those you know, do most of them have some [sexual] experience with women? Have they had experience with women before?
R: Some of them do.
I: For those who have had experience, what types of women did they have this experience with?
R: Students like us. ...
I: Are there any looking for women serving food in restaurants?
R: No. No one likes that.
I: Why don't they like to have affairs with easy women?
R: Easy women aren't good. We know, so we don't go.
I: What does it mean, not good? Why are they bad?
R: It is like they are promiscuous. They can give us diseases.
—18-year-old urban student
• Increasing opportunities for noncommercial sexual relations. Our data suggest that many men feel that at least some women their age have fairly relaxed attitudes toward premarital sexual relations. Half of the informants reported that opportunities for premarital sexual relations had increased over the past few years.
I: Are there many women who will have sexual relations with men before marriage, speaking of women who are not prostitutes?
R: A lot. Now there are a lot.
I: Why do you think a woman might have a [sexual] affair with a man if she doesn't think the guy will be her future husband?
R: They feel satisfied with it. [The man and woman] satisfy one another and agree about it. That's it. There is nothing more to it than that.
I: I don't quite understand; what does it mean, "satisfaction"?
R: Well, it has to do with the guy's appearance, character, how handsome. [Women] like them and go with them.
I: Isn't that similar to how men think?
R: It is the same.
—26-year-old urban salesman
As this exchange shows, men not only perceive opportunities for sex with female peers, but also recognize sexual desire and an interest in exploration among their women friends. For many young men, these opportunities for premarital sexual experimentation are probably replacing the more one-sided sexual experimentation with commercial sex workers.
• Women's changing views about men's commercial sex patronage. Thai women coming of age today are less tolerant of male commercial sex patronage than were their predecessors,42 a change that is undoubtedly also influencing men's attitudes. While most of our informants perceived fairly widespread opportunities for noncommercial romantic and sexual relationships, two men reported declining or few opportunities; one suggested that this was particularly the case for men who were known to continue participating in commercial sex.
I: For the men in your group, would you say that their chances to have sex with an ordinary woman [not a commercial sex worker] have increased or decreased in the past few years?
R: Nowadays? It is less.
I: Why is that?
R: Women know about us and so don't want to get involved with us....If they know we behave like this [visit commercial sex workers], they despise us....They hate it that we behave badly...going to prostitutes.
I: But if friends are going to brothels, going to prostitutes...do they discuss it?
R: They don't tell....They are afraid that friends will talk about it with others.
I: With whom do they fear their friends talking?
R: Their girlfriends.
—24-year-old rural farmer
Commercial vs. Noncommercial Sex
The relative attractions of commercial and noncommercial sexual relations were not an explicit topic of our investigation. Nevertheless, the perceived advantages of commercial sex did arise spontaneously in three of the interviews with informants.
I: Didn't [your friends] like their girlfriends?
R: Women. Sometimes [our friends] were bored with women. They didn't do like the men wished. So we had to go to service women.
—18-year-old urban student, rural background
For me, most [of the women I had sex with] were easy women, more in brothels. Because there was no bond. We knew how they were, and they knew how we were.
—24-year-old urban teacher, rural background
While informants did not spontaneously discuss advantages of noncommercial sex relationships over commercial sex relationships, other than the perception that they pose less risk for contracting disease, we hypothesize that noncommercial romantic and sexual relationships hold a number of other attractions for Thai men. Specifically, we believe that the increased privacy and intimacy of a noncommercial sexual relationship is probably attractive to many men. Only one informant alluded to perceptions of increased privacy in noncommercial relationships, however.
Condom Use During Noncommercial Sex
If commercial sexual encounters are increasingly protected by condom use, there is rising concern about the degree to which noncommercial sexual encounters are becoming an important vehicle for the spread of HIV. While the recent decline in incidence is welcome news, the large number of currently infected but otherwise healthy young Thai men (and increasingly, women) has dire implications for the future spread of the epidemic.
Our informants' responses unfortunately support the generally held fear among public health officials that condom use is not occurring in many transitory noncommercial sexual relationships. Three informants reported that their peers primarily or only used pills for contraception with noncommercial sex partners; four reported a mix of condoms and pill use (often using condoms with more casual partners and pills with more serious ones), and one (one of the two youngest informants) reported a preference for condoms within his group.
I: Have friends ever told you about the method of contraception they use?
R: Some buy pills. Some use condoms.
I: Men who use condoms, do they use them to prevent their girlfriends' pregnancy or are they more afraid of disease?
R: Preventing pregnancy.
I: Haven't they ever been afraid of diseases from women [with whom they have noncommercial sex]?
I: Even if the women had boyfriends before, [men you know] aren't afraid of contracting a disease from having sex with a woman [with whom they have noncommercial sex]?
R: Well..., well..., they do some, but....
I: Not so much.
—18-year-old urban student
I: If men you know have [sexual] affairs with women, what contraception do they mostly use? Have they ever told?
R: Using pills.
I: Isn't there anyone using condoms with women who are their girlfriends?
R: A few. I don't quite like [condoms] myself. Mostly they use pills.
I: Aren't men afraid of women having sex with other men and having diseases that they can contract?
R: They never think about that because of being boyfriend-girlfriend.
—24-year-old urban teacher
One informant explained that within his peer group, concerns about passing HIV along to one's girlfriend is a reason for consistent condom use with commercial sex workers, but the comment was elicited by the interviewer's probes.
I: Er...if they have girlfriends, they don't use condoms at the brothel? At the brothel, do they use?
R: Some use. Some don't use.
I: Meaning that if friends are going to the brothel, do all of them use a condom, or only some of them will use?
R: Some use. Some don't use....but those who have girlfriends will use.
I: Ah...Why do they use if they have girlfriends?
R: They are afraid their girlfriends will get [a] disease.
—24-year-old rural farmer
Although a qualitative approach can provide insights into the ways in which Thai men (and women) are adapting to changes in the social and epidemiological context of sexual life, this approach has important limitations. Because our research strategy necessitated purposive rather than random sampling as well as a small number of informants, our data cannot be considered representative of any population in a statistical sense. Furthermore, because we were investigating a period of time during which our informants were maturing, changes they attribute to the passage of time may instead be due to their own maturation. In most cases, however, their explicit connection between behavioral change and AIDS demonstrates the importance of the changing epidemiological and social context. Finally, it is possible that our informants responded to our questions in a socially desirable manner. We minimized this possibility by taking a nonjudgmental approach to the topic in our interviews and by focusing our questions on informants' friends, rather than on the informants themselves. Men's frequent reporting of attitudes and behavior that are socially undesirable gives us confidence that their reports were generally reliable.
The men we interviewed were keenly aware of the increased risks involved in commercial sex, especially unprotected commercial sex. Consistent with the profound changes in behavior suggested by recent survey and STD data, our data indicate that most men in the informants' social circles have responded to these escalated risks by reducing the frequency of commercial sex visits, increasing the use of condoms or abstaining from commercial sex altogether.
Underlying these changes in behavior are profound changes in attitudes and group norms regarding sex, especially commercial sex. Views of commercial sex patronage have shifted from fun and normative to worrisome and questionable. As these changed attitudes spread among young men, a decline in peer pressure to participate in risky sexual practices has also occurred. Men are more likely than before to encourage each other not to visit prostitutes. In cases where men, usually those who are slightly older, try to pressure young men to participate in commercial sex, it is much easier in the current normative environment for the younger men to decline.
It is not only commercial sex relationships that are changing. Profound changes in noncommercial sexual relationships will have important implications for both the spread of HIV and for male-female relations generally. Our informants reported that opportunities for premarital noncommercial sex are not at all exceptional. Changes in the normative sexual environment for women appear to be making noncommercial sexual opportunities for men more common. At the same time, young women are less accepting than they once were of their male peers' commercial sex patronage. Consequently, men who engage in commercial sex may find that romantic or sexual opportunities outside of the commercial sex arena are diminished.
The lack of condom use in noncommercial sexual relationships is cause for concern for men and women who are both old enough to have come of age when unprotected brothel-based sex was more common, and young enough to subscribe to the more relaxed norms now governing noncommercial sexual relationships. Cohorts of young men and women coming of age during this transitional period should be targeted by aggressive campaigns designed to encourage condom use for all types of premarital sex.
If commercial sex transactions can be expected to continue to decline as a normative expression of male sexuality, and if noncommercial sexual relations can be expected to continue to become more commonplace, it is less clear what can be expected for relationships that cannot easily be classified as either. Intimate relationships between Thai men and women that cannot be categorized as purely commercial, but do involve the exchange of money or resources, have been around for as long as Thai history has been recorded. Such relationships may eventually replace the standard brothel-based sexual relationships that are now in decline. If so, the mixture of pecuniary, hierarchical and emotional components in these relationships present a new set of challenges for controlling HIV and other STDs. Being non-brothel-based, they will be much more difficult to monitor. Furthermore, if men retain disproportionate power in hierarchical and pecuniary sexual relationships, it may be difficult for women to negotiate issues such as condom use. Finally, the emotional component of these relationships is likely to be greater than in more conventional commercial sexual relationships, which can work for or against safe-sex practices. More emotional attachment could lead to more communication and concern for each other's welfare, (although such concern about the welfare of partners was generally absent from the discussion about noncommercial sex partners in the current study). Increased emotional intimacy could also work against condom use if condoms are seen as a barrier to intimacy.
Patterns of sexual behavior are changing rapidly, and these changes have profound implications not only for the spread of HIV and other STDs, but also for marriage and fertility rates, gender relations and economic transfers. To validate and supplement our qualitative results and the large number of informative, but limited, surveys on the topic (for example, those involving soldiers), Thailand needs a state-of-the-art, longitudinal, nationally representative survey of sexual behavior. Both behavioral and serological data should be collected, so that we gain a more accurate picture of the distribution of risk-taking behaviors and infection rates within the entire adolescent and young adult population, the nature of the links between behavior and infection, key covariates of behavior and infection, and differences in the rates of change over time among age cohorts and other key subgroups. The national quantitative data provided by such a survey should be supplemented with ongoing qualitative data collection to assess how the normative context and individual attitudes shift alongside these behavioral and epidemiological trends. Given the high level of social science research expertise found in Thailand, the dedication of its national leaders to addressing the problem of HIV/AIDS and the sophisticated and frank discussions of sexuality currently occurring within the Thai populace, we would stand to learn a great deal from a study documenting the extensive changes now under way, as well as the causes and consequences of these changes.
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Mark Vanlandingham is associate professor and Lea Trujillo is a graduate studentat the school of Public Health and Tropical Medicine, Tulane University, New Orleans, LA, USA
The research on which this article is based was supported primarily by the Mellon Foundation. The authors thank John Knodel, Chanpen Saiengtienchai, Anthony Pramualratana and Rebecca Mowbray for their insights. They also thank Leudech Girdwichai, Somsak Nakhalajarn, Sureeporn Punpuing and Nuatip Butbuanit for their superb research assistance and logistic support. A longer version of this article that includes more methodological detail and expanded findings is available from the first author, and can be downloaded from http://www.psc.isr.umich.edu/pubs by searching by the author's name.