SEXUAL BEHAVIOUR AND AIDS IN : STATE-OF-THE-ART

MONI NAG

With no vaccine in sight for immunisation against the AIDS-transmitting virus, HIV, the only feasible method of controlling the spread of the disease seems to be through behavioural prevention. There is an urgent need for an awareness to be created among the people regarding those aspects of sexual behaviour which are particularly risky with regard to HIV transmission. Topics such as premarital sex, extra marital sex, female sex workers, , hijras and male sex workers are covered by the paper. High risk sexual behaviour involving the above aspects are not as uncommon in India as generally assumed, according to evidence. Dr. Moni Nag is Adjunct Professor of Anthropology, Columbia University, New York and Senior Consultant, Johns Hopkins University's School of Hygiene and Public Health, Baltimore, U.S.A.

Introduction Even the scientist seems to have underestimated the faith of the man of the street in the scientific method, his respect for the results of scientific research, and his confidence that his own life and the whole of the social organisation will ultimately benefit from the accumulation of scientifically established data. Kinsey, A.C. et al. in Sexual Behaviour of Human Male (1948) Although HIV (human immunodeficiency virus), the virus responsible for AIDS (acquired immune deficiency syndrome) can be transmitted through blood/blood products and from pregnant/lactating mother to her child, the principal mode of transmission in India is through sexual relations — primarily, heterosexual inter­ course. So far no vaccine for immunisation against HIV or cure for AIDS is available; nor is there a hope for any such in the foreseeable future. Hence the spread of AIDS can only be controlled through behavioural prevention. Since sex is a basic need for both pleasure and reproduction for most people, an effective way of preventing AIDS is to have a better understanding of what aspects of sexual behaviour are particularly risky for HIV transmission in India and to make people aware of them. But in order to achieve that we need to know much more than what we know at present about the existing patterns of sexual behaviour in diverse population groups of India.

Sex is usually not a matter of overt discussion in India, but the threat of AIDS as a killer disease has made it a legitimate topic of allusion in Indian mass media. Much of the underlying assumptions behind the allusions are based on myths and stereotypes which may be far removed from real facts. India can boast of Vatsyay- ana who wrote the extraordinarily analytic treatise on sex and love, , more than 1,500 years ago, but it, as well as other ancient Indian writings on sex, hardly gives us any glimpse of the patterns of actual sexual behaviour of common people. Even in contemporary India only a small section of people seems to be familiar with Kama Sutra, mostly through its English version first published in 1883 by Burton and Arbuthnot (1993), and is perhaps interested mainly in the visual representation of various techniques of sexual intercourse vividly described in it: 504 Moni Nag

The ambivalence and inhibitions regarding sex in the minds of educated Indians are illustrated by the fact that Kama Sutra was kept in University library at least up to the late 1980s in a locked backstage room and even a faculty member had to take special permission to borrow it (Ganguli, 1988). The limited amount of studies done on sexual behaviour in contemporary India has concentrated on the diagnosis and treatment of sexual illness or pathology from psychiatric, psychological or physiological perspectives or from a combination of these. This is true for many other countries also (Mundigo, 1992), but the AIDS pandemic has generated national surveys in a few countries such as England, France and USA, aimed at understanding patterns of sexual behaviour. Much of these studies is exploratory and has an applied objective. In India, no national survey has been conducted as yet, but the National AIDS Control Organisation (NACO) of the (India NACO, 1993a: 44-48) and a few NGOs (Pachauri, 1992) have initiated some studies on sexual behaviour in a number of urban and rural areas.

Situation in India The numbers of full-blown AIDS and HIV seropositive cases in India officially reported so far are small compared to many other countries. Since May 1986 when the first AIDS case was reported (infected through blood transfusion in the USA), 440 cases of AIDS (336 males and 108 females) among Indians in India upto 30 September 1993 (India NACO, 1993b). The number of reported cases represents only a small proportion of the actual AIDS morbidity because, among other reasons, diagnosing AIDS presents insurmountable difficulties in India. As a proportion of India's total population of about 890 million, this figure is insignificant compared to some countries in Africa and the West, for example, 30,190 AIDS cases in Uganda (population 22 million) and 2,13,641 cases in the USA (population 255 million) up to the end of 1991. The low number of AIDS cases in India also reflects the fact that HIV infection started relatively late and that relatively large number of AIDS cases are undiagnosed and unreported in the country. The number of AIDS cases reported so far, however, show wide geographical variation within the country. Out of 310 reported cases mentioned above, Maharashtra and accounted for 93 and 92 cases respectively. The remaining 125 cases were reported from 16 other states/union territories.

According to the national surveillance network, out of 18,89,670 individuals (mostly belonging to vulnerable groups such as female sex workers (FSWs), intravenous drug users, blood donors, antenatal clinic attendants and STD clinic attendants) tested from October 1985 to March 1993, 13,254 (7.4 per 1,000) were found to be infected with HIV. The National AIDS Control Organisation (NACO) estimates the number of HIV seropositive cases in the total Indian population as about one million by the end of 1992. So far the preponderance of reported HIV cases is in Ma­ harashtra, Tamil Nadu and Manipur states. The major concentration of infection is in Bombay city which alone may contain 5 to 10 per cent of the country's infected individuals. The other cities known to have high concentration of infected individuals are Pune, Madras and Vellore. In consideration of proportion of population infected Sexual Behaviour and AIDS in India 505 with HIV, the northeastern states of Manipur, and Mizoram rank high because of the relatively wider use of intravenous drugs in those states. Heterosexual promiscuity has been the principal mode of transmission of HIV in India so far except in the northeastern states. Multi-partner sexual relationship on the part of men and women accounted for 75 per cent of infection among 310 AIDS cases reported up to March 1993. Therapeutic blood transfusion accounted for 12 per cent and sharing unsterilised equipment by intravenous drug users for 7 per cent. In some selected groups of FSWs (female sex workers) 35 per cent or more were tested as HIV positive in 1992 and in some groups of males with multiple sexual relationship 16 per cent were so. The HIV prevalence rate in intravenous drug users is very high (54-74 per cent in Manipur and 50 per cent in Nagaland), but it is quite likely that some of them got the infection through sexual relationship.

The HIV transmission rate through blood transfusion is quite high in India because until recently only a small proportion of blood used for the purpose was tested for HIV and also because a considerable proportion of blood for transfusion comes from professional blood donors among whom the prevalence of HIV is high. Among 15,297 blood donors in a few selected samples tested in 1992, 0.85 per 1,000 were HIV positive. In Madras and Bombay the proportion of blood donors infected was much higher — 23 per 1,000 in each city.

Other possible modes of transmission of HIV are through male homosexual rela­ tionship, from infected mothers to their children during , and lactation, and through injection needles and other sharp equipments contaminated with infected blood. No data is available regarding the extent of male homosexual relationship and the prevalence of HIV among male homosexuals in India. Tests conducted among 6,031 pregnant women in some selected populations in 1992 show that the HIV prevalence rate per 1000 pregnant women was 1.16. If this figure represented the average prevalence rate among all pregnant , then an alarmingly large number of infants are being born currently in India with HIV infection because 20 to 40 per cent of the infants born of infected mothers are likely to carry the infection (Anderson and May, 1992: 69). According to one estimate, however, every year 20,000 out of 24 million deliveries in India are likely to occur in HIV positive women (Ramachandran, 1992). There is no data regarding HIV transmission in India through injection needles (other than those used by intrave­ nous drug users) and other sharp equipments. With increasing number of HIV- infected individuals around, the risk of such transmission is likely to increase mainly because in India such needles and equipment are often not sterilised properly. The risk of infection through sharp razors used for shaving by millions of street and saloon barbers, and through sharp instruments used for skin piercing are particularly high in India.

Although the validity of the estimates of the actual AIDS and HIV prevalence in the total population extrapolated from the number of cases reported is questionable, the evidence regarding the rapid rate of increase in prevalence in various population groups and subgroups in recent years is quite clear and seems to justify the labelling of India as a dormant volcano for HIV and AIDS pandemic. Stated below are a few examples of such evidence: 506 Moni Nag

• Out of 290 AIDS cases reported up to the end of 1992, 187 (65 per cent) were reported in 1992 alone and numbers reported in 1991,1990,1989 and 1986-1988 were only 43, 26, 20 and 15 respectively. • HIV prevalence rate among individuals tested through nationwide surveillance network were 2.5, 4.9, 5.5, and 11.2 per 1000 respectively during two-year periods from October 1985 to December 1992. In some countries where HIV infection was detected in the early 1980s and some preventive steps were taken early (for example, Canada, the USA, Italy and Tanzania), annual figures for new infection have tended to plateau in the early 1990s (Mann et al., 1992: 893-897). • HIV prevalence rate in selected samples of males with multiple sex partners increased from 5.6 per 1,000 in 1991 to 16.2 per 1,000 in 1992. • HIV prevalence rate in selected samples of FSWs in Vellore increased from 5 per 1,000 in 1986 to 345 per 1,000 in 1990 and in Bombay from 10 per 1,000 in 1986 to 180 per 1,000 in 1990 and to 350 per 1,000 in 1992. • HIV prevalence rate in selected samples of blood donors in Bombay increased from 10.5 per 1,000 in 1991 to 22.9 per 1,000 in 1992, and in Madras more drastically from 1.7 per 1,000 in 1991 to 23.1 per 1,000 in 1992. • HIV prevalence rate in selected samples of pregnant women increased from 0.6 per 1,000 in 1991 to 1.2 per 1,000 in 1992. If HIV prevalence rate among various population groups continue to increase at the same pace as indicated above, it is estimated that by 2000 AD about 5 million individuals would be infected in India and the number of AIDS cases would exceed one million. These estimates made by NACO, although mind-boggling, are some­ what lower than others, such as 6 million or more HIV-infected only among adults by 2000 AD (McDermott, 1991: 10). All these estimates are, however, made on many assumptions which need to be validated through systematic social science and biomedical research. Moreover, appropriate preventive actions should be able to control the pace of increase in HIV prevalence, as has already been demonstrated in some countries.

Awareness about AIDS and HIV The central and state governments have launched IEC (information, education and communication) programmes through mass media and other means for increasing awareness about AIDS. Many NGOs have also launched similar programmes. As a result of these and publication of reports (often scary) in popular newspapers and magazines, the awareness about AIDS as a very threatening disease is perhaps quite widespread by now (end of 1993) in India — even in its rural areas. But very little is known about the depth of awareness in different sections of the population. Very few studies with this objective have been conducted so far. Salient findings from a few of recent studies are cited below according to the sections of population studied.

Physicians and other Health Personnel A survey of 200 practicing physicians of various specialities in Medical College who graduated before 1980 (Thirumalaikolundu Subramanian et al., 1992) showed that: Sexual Behaviour and AIDS in India 507

• 75 per cent were aware that they were prone to accidental infection and majority (50 to 60 per cent) were not willing to take up AIDS/HIV cases • Only 12 per cent, 7 per cent, 8 per cent, and 5 per cent knew that HIV could be eliminated by soap, boiling water, hydrogen peroxide and household bleach, respectively • 76 per cent were aware that the risk was high among STD patients and laboratory personnel • 86 per cent felt that AIDS was a rare disease and there was no need for uniform safety precautions for all physicians.

A survey conducted among 109 Medical Officers of Primary Health Centres in Maharashtra in July-December 1991 (Divekar and Banerjee, 1992) brought to light that:

• concepts of HIV transmission through heterosexual relations and blood were fairly clear to all, but 14 per cent mentioned faces and hair as infecting agents and 10-20 per cent felt that hugging, masturbation or sneezing by infected persons could transmit HIV • majority had a fair idea of symptoms of AIDS • 44 per cent did not understand the significance of HIV antibody; 19-26 per cent attributed tuberculosis and poverty as the cause of HIV infection • 31 per cent were aware of contracting HIV as a professional hazard.

A survey of 142 physicians in Bombay and Sholapur cities in 1992 (Chitale et al., 1992: 61-62) showed that:

• 19 per cent mentioned sexual relationship with FSWs as a mode of HIV trans­ mission • 40 per cent mentioned sexual relationship with multiple partners as a mode • 45 per cent mentioned blood transfusion as a mode • 12 per cent did not know the difference between HIV and AIDS.

Students

A survey of 409 students (18-24 years, majority undergraduate) in Bombay (185), New Bombay (110) and Sholapur (114) cities in 1992 (Chitale et al., 1992: 15-19) indicated that:

• 10 per cent of students in Bombay, 23 per cent in New Bombay and 34 per cent in Sholapur were not aware of AIDS • Only 5 per cent of students in Bombay, 0 per cent in New Bombay and 5 per cent in Sholapur stated that AIDS could be transmitted through infected blood • Only 11 per cent of students in Bombay, 4 per cent in New Bombay and 0 per cent in Sholapur mentioned sexual relations with FSWs could be a mode of transmission • 19 per cent of students in Bombay, 28 per cent in New Bombay and 13 per cent in Sholapur thought that AIDS was a curable disease • 95 per cent of students in Bombay, 50 per cent in New Bombay and 48 per cent in Sholapur knew that it was an infectious disease. 508 Moni Nag

Truck Drivers The result of a survey of 200 truck drivers in Delhi in 1988 (Singh et al., 1992) are given below: • 78 per cent admitted to being heterosexually promiscuous • Only 20 per cent had heard of HIV/AIDS and only a quarter of them knew that HIV could be transmitted through sexual intercourse • A sexual survey of 100 truck drivers after a communication campaign using pamphlets, posters and group discussions revealed that awareness about HIV/AIDS had increased to 55 per cent. Another interview survey of 101 truck drivers near in May, 1993 (Mani, 1993) revealed that: • 80 per cent admitted to having sex with FSWs • 89 per cent never used condoms (with prompting 24 per cent had started using them). They commonly felt that since nothing serious had happened to them so far, nothing could happen in the future either.

Rural Population A survey of 669 men and 829 women near Delhi and in Haryana (Chuttani et al., 1990; cited in Mane and Maitra, 1992: 83-86) gives the information that: • 50 per cent of men and only 12 per cent of women were aware of AIDS • Among those who were aware a fairly large percentage knew about transmission through sex • A fairly large percentage of men knew about transmission through infected needles and blood; some men mentioned homosexuality • Less than 50 per cent knew about the fatal nature of AIDS • Only a small percentage had some knowledge of symptoms of AIDS • 92 per cent of men and only 29 per cent of women stated that for prevention of AIDS sex with FSWs should be avoided; only one man mentioned condom usage. It is very difficult to make any general conclusion from the findings cited above except that awareness about AIDS and HIV is perhaps still superficial and alarmingly incomplete in all sections of population. The superficiality of knowledge even among physicians and students (18-24 years) in cities (Chitale et al., 1992) indicates the urgency of vigorous efforts by government and non-government agencies to step up their IEC programmes tailored to the needs of diverse groups of population. This can only be done through a better understanding of the existing patterns of sexual behaviour relevant to prevention of AIDS and other sexually transmitted diseases.

Organisation of the Present Paper The risk of sexually transmitted diseases is higher in sexual relationships with multiple partners than in monogamous relationships. Premarital sexual relationships of men and women may involve single partner or multiple partners. Extramarital re­ lationship by definition involves multiple partners. A large proportion of extramarital Sexual Behaviour and AIDS in India 509 relationships of Indian men is with FSWs. But the available evidence, however meagre, indicates that their extramarital relationships with women other than FSWs is not as uncommon as generally assumed. This is also true for extramarital relationships of women with men other than their husbands. Sex workers, female or male, have to almost invariably entertain a multitude of sexual partners for their livelihood, whether they like to do so or not. Male homo­ sexual relationship most probably carries a higher risk of HIV transmission than heterosexual or relationship because of a higher occurrence of anal inter­ course among male homosexuals and also because of the higher probability of multiple partnership among them arising partly out of social and legal non-ac­ ceptance of homosexual marriage. Members of the community in India — a group of mostly castrated (emasculated) males — who indulge voluntarily or forcibly circumstances to have homosexual relationships similarly carry a high risk of HIV transmission. Two principal ways of preventing sexual transmission of HIV infection are to use condoms in sexual intercourse and to abstain from sexual acts involving individuals with a high risk of HIV transmission. It is necessary to assess the existing knowledge, however fragmentary, on the aspects of sexual behaviour mentioned above in India and to identify priority research areas with reference to AIDS/STD prevention.

The organisation of the present paper around the following topics is based on the above assumptions of high-risk sexual relationships and principal ways of prevent­ ing sexual transmission of HIV infections; premarital relationship; extramarital relationship; female sex workers; homosexuality; hijras and male sex workers; use of condoms; sexual abstinence; and priorities of research.

Premarital Sex

Attitude Towards Premarital Sex A study conducted by Counselling Research Therapy Training (SECRT) division of the Association of India (FPAI, 1990) in 1989 contradicts some stereotyped notions regarding attitude towards premarital sex in India. Survey questionnaires were distributed to 16,000 unmarried men and women of the age group 15-29 years in selected FPAI urban branches of India. Of 3,846 persons (45 per cent male, 55 per cent female) who completed them, 65 per cent were college graduates and 35 per cent undergraduates. The frequencies of their responses to nine statements representing various shades of views regarding premarital sex are presented in Table 1.

It can be observed from the table that attitudes towards premarital sex among young, educated and unmarried men and women of contemporary India vary considerably. The traditional concept of premarital sex as a sin is held only by 23 per cent men and 30 per cent women. Forty per cent of men and 33 per cent of women disagreed with the view, contradicting the stereotype commonly held by a large section of Indian population. Perhaps more surprising is the fact that 16 per cent of men and 5 per cent of women were radical enough to agree with the statement that "both young men and women must have sex before marriage." A remarkable shift from 510 Moni Nag the traditional condemnation of premarital sex both among men and women is also revealed in a substantial percentage of men (46 per cent) and women (44 per cent) agreeing with the statement that "having premarital sex is the concern of the individual and not society". TABLE 1 RESPONSES OF 2115 UNMARRIED WOMEN AND 1731 MEN OF 15-29 YEARS TO ATTITUDINAL STATEMENTS REGARDING PREMARITAL SEX*

* Compiled from FPAI, 1990.

It is obvious from the responses to all the statements that men were more liberal in their views than women. For example, a considerably higher proportion of men than women agreed with the views that officially engaged couples and couples in love may have premarital sex. A more permissive attitude towards premarital sex among men than among women is reflected in higher percentage of positive responses among men than among women. Eighteen per cent of men compared to only 3 per cent of women agreed with the statement "I may have premarital sex but my marriage partner should not." Also, 14 per cent of men compared to 9 per cent of women agreed with the statement "A man may have premarital sex but a women should not". Information regarding attitude towards premarital sex was collected in another survey conducted mainly for assessing adolescents' knowledge and attitude related to family planning (FPF and ORG, 1992: 113-115). It was a self-administered questionnaire survey carried out in 1991 among 17,185 (13,331 male and 3,859 female) school students of 9th, 10th and 11th standards (99 per cent 18 years or Sexual Behaviour and AIDS in India 511 under) in urban and rural areas of , , Haryana and Delhi. Five per cent of male students and 3 per cent of female students were married. The frequencies of their responses to four specific statements regarding premarital sex are presented in Table 2. TABLE 2 RESPONSES OF 17,185 MALE AND FEMALE SCHOOL STUDENTS TO ATTITUDINAL STATEMENTS REGARDING PREMARITAL SEX*

The Majority (51 per cent) of students agreed with the statement that "unmarried people should not have sexual intercourse", but in the Indian sociocultural context a higher percentage would be expected to hold this view. What is quite unexpected is that one-quarter of the students agreed with the statement that "I believe in getting sexual pleasure where and when I get it". The fact that 28 per cent agreed with the liberal view that "it is alright for two people to have sexual intercourse before marriage if they are in love" also reflects a trend towards liberal sexual morals among the young. This trend is reflected, however, more in views expressed by male students than those by female students. For example, 31 per cent of male students as compared to 17 per cent of female students agreed that it was alright for two people to have sexual intercourse before marriage if they were in love. Also, 28 per cent of male students agreed with statement 4, while only 13 per cent of female students did so. Kapur's (1973: 210-225) study of 500 educated working women in Delhi metropolis in 1958-1968 showed that the perceived limits within which sexual freedom should be allowed to unmarried boys and girls had widened within a decade. At the initial phase of the study only 5 per cent of women thought that this freedom could go up to passionate kissing, embracing and indulging in other physical intimacies (except sexual intercourse), provided the couple loved each other and planned to marry or were already engaged to be married. Ten years later, 31 per cent were willing to extend these limits to unmarried men and women if they were "consenting adults and mature people". At that time 5 per cent said that the limits could be extended to include sexual intercourse, if it was based on love, confined to one particular partner and not exploitative and harmful to anyone. The change was not insignifi­ cant, considering that the subjects were middle class working women. Case studies 512 Moni Nag showed, however, that their views about their own behaviour did not become as liberal as their views about others' behaviour. Kapur's questionnaire included the following question: "What prohibits or inhibits a girl from indulging in sex before marriage with a boy whom she loves or plans to marry?" The typical nature of responses changed in 10 years. At the initial survey the reasons given were mostly "own principles", "own morals", "belief that a girl should be virgin before marriage" or "fear of pregnancy". Ten years later, appre­ hension that the lover may cease to love and respect the girl, and may even refuse to marry her if she indulged in sex was given as dominant reasons. This apprehen­ sive attitude is also reflected in general agreement among the respondents 10 years later that most men still wanted to marry a virgin. It implies that in 10 years women became less moralistic but more calculating.

A study among 134 students and 148 non-students in a few Bombay undergraduate colleges in the early 1960s showed that 65 per cent of students and 62 per cent of non-students disapproved of premarital sex relations (Fonseca 1966: 153-154). Forty two percent of students and 63 percent of non-students were male. Premarital sexual relations were accepted only by seven male students, seven male non- students and one female student on the ground that suppression of sexual drive was immoral and might lead to "pervert auto-eroticism". Disapproval was voiced more by women than men and reasons for it included fear of consequences, religious beliefs, concept of sin associated with sex and the attitude that it was "suicidal for girls".

Practice of Premarital Sex

Anthropological literature on the tribal societies of India refers to the wide prevalence of premarital sex in many of them (for example, Elwin 1939:219-220; 1947:459-474) but reliable information on the practice of premarital sex among the mainstream population of India is rare. A few recent studies indicate, however, that the practice is not that uncommon in both educated and uneducated and in both urban and rural populations.

A survey conducted in the early 1980s among male and female students (14-28 years) of a few colleges in Madras city regarding sexual behaviour and attitude is quite revealing (Reddy et al., 1983). A questionnaire with stamped envelope was distributed to about 9,600 students. Responses were received from 634 male and 486 female students. About 61 per cent of male and 48 per cent of female students stated that they had their first sexual experience before they attained 25 years. Since 96 per cent of male students and 93 per cent of female students were unmarried, it can be presumed that the majority of male students and a substantial minority of female students had already experienced premarital sex. The actual prevalence of the practice among the total population of college students may be somewhat lower since it is likely that the 1,120 students out of 9,600 who responded to the anonymous questionnaire were more uninhibited regarding sex than the others. However, the high percentage of Madras college students admitting premarital sexual experience does not seem to be inconsistent with the findings of a recent study of a sample of boys in Delhi (Sehgal et al., 1992) in which 25 per cent admitted Sexual Behaviour and AIDS in India 513 to having sexual intercourse. It is interesting that the first sexual encounter of 11 per cent of male and 23 per cent of female students of Madras colleges was with a person of their own sex. The views of the students who responded to the question­ naire regarding sex education and open discussion of sex were quite liberal. For example, 76 per cent of male students and 60 per cent of female students were in favour of introduction of sex education in schools and colleges. The unexpectedly high prevalence of premarital sex among educated middle and upper middle class population in India is revealed in a study based on the responses given to a questionnaire on sexual behaviour published in a 1991 issue of Debonair — an expensive and erotic magazine claiming an all-India circulation of 85,000 (Savara and Sridhar, 1992). The responses obtained from 1,424 men (over 78 per cent with college and higher degrees and 48 per cent married) show that 30 per cent of them had experienced premarital sex. Fifty-one per cent of unmarried men and 33 percent of married men had their first intercourse before attaining 20 years. It is interesting to note that the percentage of respondents with premarital sexual experience is higher for higher age groups signifying that such experience, at least among the class of people which the sample reflects, is not a relatively recent behavioural phenomenon. For example, 62 per cent of men of 45-55 years had premarital sex compared to only 20 per cent among men of 25-29 years. Among those who had any sexual experience, 29 per cent had their first premarital experience with friends, 23 per cent with their respective spouses, 22 per cent with paid persons, 13 per cent with relatives, 10 per cent with casual acquaintances and 3 per cent with work acquaintances. Ten per cent had their first intercourse with men. Out of 718 unmarried respondents 28 per cent had sex with FSWs and over one-half of them had it with six or more FSWs.

Savara and Sridhar (1993) have also analysed the data regarding premarital sexual experience of a sample of 383 well-educated women of upper income households who responded to a questionnaire published in a 1992 issue of Savvy—an expensive magazine for women. About 80 per cent of them had college or higher- level degrees and belonged to households with income mostly above Rs. 5,000. About one-quarter of them were unmarried and about 65 per cent of them reported experience of sexual intercourse, nearly one-half of them having it before 20 years of age. About one-quarter of married women said they had sex with their husbands before marriage. Other premarital sexual partners for both married and unmarried women were mostly friends, relatives and work acquaintances. Forty-three per cent of all respondents agreed with the statement that it is alright to sleep with someone who has no plan to marry them. Such a permissive attitude towards premarital sex casts doubt about how far the sample of respondents represents even the educated upper class people of India.

Another study conducted by the Indian Market Research Bureau in early 1993 in a small sample of middle and upper middle class women (perhaps not very different from Savvys readers) revealed that 23 percent of the respondents had premarital sex (Femina, 1993). Forty-one per cent of the respondents who indulged in premari­ tal sex did so as teenagers, with a quarter of them being involved with men other than their spouses. 514 Moni Nag

The studies reviewed above indicate that although premarital sexual relationship is generally considered as immoral in contemporary India, a substantial proportion of young men and women did not find it objectionable under all circumstances. There is, however, very little information about the extent of premarital sex experienced by people of diverse socioeconomic strata in rural and urban India. The surveys cited above were mostly conducted among educated, urban middle and upper middle class groups and samples selected hardly represented even those groups. However, it can be conjectured that gradual openness about sex in Indian cinemas, video music, television, popular magazines and other entertainment media during the last two or three decades is increasingly influencing the unmarried youth to be more adventurous about premarital sex than ever before. As a result, the extent of premarital sex with multiple partners, particularly by unmarried men, may be considerably higher than what is commonly perceived.

Extramarital Sex Sex outside marriage is likely to be more common among men than among women in India because of the power and freedom enjoyed by men in a patriarchal society and easy availability of female sex workers (FSWs). Fidelity within marriage is the predominant norm for both men and women among all sections of Indian population but, in general, sanctions against extramarital affairs and sex are more severe against women than men. concept of pativrata — the ideal for a woman to remain loyal to her husband under all circumstances — has no counterpart for men. In a study of caste of Maharashtra, it was found that women viewed their husbands' extramarital sexual relationship as a "male" characteristic which, if accepted or ignored, provides them with extra "power" and enables them to stay with their husbands (Bhave, 1990; cited in Mane and Maitra, 1992).

Extramarital relationships of men with FSWs are covered in the next section on FSWs. Anecdotal reports about extramarital relationships of married men with women other than spouses and FSWs, and of married women with men other than spouses are available in social science and popular literature but reliable data about attitude towards and practice of such relationships in India is virtually nil. Findings from a few studies are cited below. Kapur's (1973: 211-219) survey of 500 educated working women in Delhi metropolis in 1958 and again in 1968 showed a change in attitude towards extramarital sex among them in a single decade. In 1958, 80-85 per cent of women had said they would feel very guilty if they happened to indulge in extramarital sexual intercourse and would not expect to be forgiven by their husbands if the latter found out. Most of them were liberal enough to think that they should be allowed to mix with men in groups (for example, at parties) or when accompanied by husbands. Some of them thought that they could go out with other men with approval from their husbands. A few of them went far enough to suggest that the outermost physical limit of their extramarital relationship could go up to indulging in hand holding, casual kissing and embracing, provided there was sincere love between them.

Ten years later also, 69 per cent disapproved of extramarital sex but the proportion who thought that "married women would be justified under certain subjectively Sexual Behaviour and AIDS in India 515 significant need-satisfying conditions to indulge in extramarital sexual intercourse" and might actually indulge in it increased from 11 per cent in 1958 to 31 per cent in 1968. Also, the proportion who stated that they would expect their husbands to forgive them if they happened to commit adultery under certain circumstances increased from 20 to 55 per cent — a remarkable change towards permissiveness. In 1968, as many as 19 per cent reported that they would not feel guilty if they happened to indulge in extramarital sex, provided there was genuine love between them and their partners and it was done with mutual consent. However, even in that year the majority held that the outermost physical limit of extramarital relationship should not extend up to sexual intercourse but the proportion allowing the limit up to kissing and embracing increased considerably. The reasons cited by the 11 percent women in Kapur's sample of 1958 in justification of their support for extramarital sex included husband's refusal or inability to have sex or his concern only with his own sexual satisfaction rather than mutual satisfac­ tion. Ten years later some women thought that even the need for a change or variety or joy of novelty could be a justified reason for a wife's adultery. It implies that at least some women started viewing sex as a physical need for women as well as for men. Majority of women, at both points, however, thought that women should not be given as much sexual freedom as men because consequences for deviations from the sexual norm, in terms of loss of reputation, respect and self-esteem were more serious for women than for men. The perception of respondents that society still maintained different norms of sexual morality for men and women practically remained unchanged. Out of 686 married men who responded to the Debona/rquestionnaire (Savara and Sridhar, 1992), as many as 381 (56 per cent) reported to have had sex with persons other than their spouses. The partners of their extramarital sexual experience included friends (53 per cent), casual acquaintances (26 per cent), relatives (26 per cent) and colleagues (18 per cent). Although 221 (32 per cent) of them admitted to having sex with FSWs, perhaps its frequency was higher in their premarital stage. It is likely that the respondents, being in a privileged socioeconomic class, had better opportunities for having extramarital sex with women other than FSWs. Over 60 per cent of 381 respondents reported having had five or more extramarital partners, presumably not all at the same time. A significant proportion of women who responded to the Savvy questionnaire also reported to having had extramarital sexual experience but it was not as high as that of men who responded to the Debonair questionnaire although both groups be­ longed to similar socioeconomic classes (Savara and Sridhar, 1993). Out of 296 married women, 44 (25 per cent) said that they had sex with a man other than their spouses after marriage and majority of them had it with only one or two men. As many as 213 women (72 per cent) said they had no desire to have an extramarital affair. As among men, women's extramarital sex partners included friends (64 per cent), relatives (21 per cent), casual acquaintances (16 per cent) and colleagues (16 per cent). Only 6 women (1 per cent) admitted being paid for sex and 19 women (6 per cent) said that they experienced group sex. 516 Moni Nag

Women respondents in the Femina-IMRB survey (Femina, 1993) were more con­ servative regarding extramarital sex than the women who responded to the Savvy questionnaire although the socioeconomic class affiliation of both the groups seem to be similar. Only 7 per cent of married women in the Femina-IMRB survey confessed to having had extramarital sexual relations. Almost half of them had male friends and 67 per cent of them shared confidences with male friends but 83 per cent of those friends were approved by the respondents' husbands. The following response of a woman perhaps reflects the typical attitude of many women inter­ viewed towards extramarital relationship: "A platonic relationship can certainly exist if both parties are sincere in letting it remain so."

Female Sex Workers (FSWs) Indian news media have been trying for some time to make people conscious of the fact that unless all-out efforts are made urgently at public and private levels to prevent the currently rapid spread of HIV infection, India may have the largest number of HIV carriers in the world within the next one or two decades. However, the mainstream Indian population in both urban and rural areas — both educated and uneducated — are still generally apathetic towards the threat from HIV and AIDS. Three obvious reasons for such apathy are: (1) very few deaths attributed directly to AIDS have been reported so far in India; (2) most of the people already infected with HIV look healthy and continue to lead their normal life without any knowledge and negative effect of their infection; and (3) there is a common perception, mostly propagated through distorted media reports, that AIDS is a disease almost exclusively confined to female sex workers (FSWs) and their clients. Since the widely-publicised initial detection of HIV infection among a few FSWs in Madras in 1986 and the death of a FSW in J.J. Hospital, Bombay in 1987, popular newspapers and magazines have been reporting often the results of HIV tests among samples of FSWs in the red light areas of Bombay, Delhi, Calcutta and other Indian cities. The Indian Health Organisation's report of the rapid rate of HIV infection from less than 1 per cent in 1986 to over 30 per cent in 1992 based on a sample of FSWs in Bombay is often cited by the news media all over India. The fact that the projections of mind-boggling numbers of HIV infected people in India in the near future are based mainly on some facile assumptions about the number of FSWs in the country and the average number of their clients per day also contributes towards blaming the FSWs for the impending threat from AIDS.

History of Prostitution or the practice of indulging in promiscuous sexual relations for money or other favours is an age-old institution in India. Kautilya's , written in circa 300 BC, has a chapter on "Ganikas" (female sex workers) which describes the norms, behaviour, prerogatives and responsibilities of the FSWs (Basham, 1959: 184). It suggested the appointment of a state official who should be responsible for the care and supervision of FSWs, inspection of brothels, and the collection of two Sexual Behaviour and AIDS in India 517 days' earnings from each FSW every month as tax to the government. It also recommended that, since the brothels were visited by many men of doubtful character, the FSWs should be enlisted in the secret service as spies. Megasthenes, the Greek scholar who visited India in 302-219 BC remarked that spies did much of their work with the help of FSWs. Vatsyayana's Kama Sutra, written between circa 1st and 4th century AD, refers to courtesans and eunuchs who depended for their livelihood on providing varieties of sexual pleasure to men (Burton and Arbuthnot, 1993). The citation of a long list of 64 qualities courtesans should acquire besides being endowed with beauty and good disposition indicates that the courtesans referred to in Kama Sutra catered only to high class men.

History of System Devadasi system of purchasing young girls and dedicating them to temples, which often made them objects of sexual pleasure for temple priests and pilgrims, was an established custom in some parts of India by 300 AD. In the Middle Ages (from the sixth to sixteenth century) gods in some Hindu temples were treated like kings; they had wives, ministers and attendants (Basham, 1959:185-186). Attendants included unmarried women known as (handmaidens of god) who attended gods' persons, danced and sang before them, and like the servants of an earthly king, bestowed sexual favours on the courtiers whom he favoured, in this case male worshippers who paid generous fees to the temple. These women were often the children of mothers of the same profession, born and reared in the temple com­ pounds, but they also could be daughters of other couples, offered in childhood to god for gaining spiritual merit or other favours from him. The earliest record of such religious prostitution come from Prakrit inscriptions in a cave at Ramgarh, some 160 miles south of Varanasi. The script shows that they were written not long after the days of King Asoka. But there are no other clear references to devadasi until the Middle Ages. Many inscriptions and charters of medieval southern India commemorating donations to temples refer specially to devadasis.

The institution of devadasis in temples was more common in southern India than anywhere else and was not weakened there despite its strong disapproval by Manu and other Hindu Smriti writers of the Middle Ages. Over the years, devadasi have become victims of sexual exploitation by temple priests as well as pilgrims. Many of them have been compelled to take up prostitution either on a regular or part-time basis. During recent years the presence of such devadasis dedicated to the goddess Yellama in a number of Karnataka temples has often been reported in the news media. A considerable proportion of FSWs in Bombay and some cities in Karnataka have a devadasis origin. Out of 350 FSWs interviewed by Punekar and Rao (1962) in Bombay, 113 were originally devadasis.

History in Calcutta during British Rule There are reasonably good records of the presence of FSWs in Calcutta under British rule (Ghosh and Das, 1990). The House Assessment Book published by Corporation of Calcutta in 1806 mentions 2,540 FSWs in 593 brothel houses located 518 Moni Nag in 82 streets of Calcutta. Of them 1,206 were Hindus, 715 Europeans and 629 Muslims. At that time prostitution was not perhaps considered as degradable a profession as it was since the latter half of the 19th century. Some FSWs, particularly among Europeans and Muslims, were apparently affluent. The tax-payers of about 6 per cent of Calcutta's property were FSWs. A report prepared by C. Fabre Tonnere in 1867 mentions the number of FSWs in Calcutta as over 30,000. Since the 1870s, however, the reported number of FSWs started to decline, perhaps because the British administration started considering FSWs as "fallen women". "Committee of Calcutta Home for Fallen Women" was formed in 1872. In the 1911 census the number of women classified under prosti­ tution as an occupation was 13,271. By the 1870s the colonial government became concerned with immoral trafficking in children, and in 1872 sent a circular to all District Magistrates inquiring about the recruitment of young girls under nine by FSWs to ply their trade (Chatterjee, 1993). As an "intelligent native" the famous Bengali novelist, Bankim Chandra Chattopadhayay, who was a Deputy Magistrate in at the time, was asked to write a report on the topic. While surveying the general condition of Bengali women who ended up as FSWs, the report focused on the causes and motives which led widows and middle class women around Calcutta and in Murshidabad district to desert their homes and "to prefer such a degraded and miserable life to domestic virtues and comforts". The principal causes identified by him were:

(i) seduction by "unprincipled villains" who subsequently left the women to their fate, (ii) intolerable cruelty of a husband or a relative, and (iii) "ennui" and "love of excitement" on the part of some women who dared to break through the seclusion and restraints of a Hindu family and found the doors of re-entry into the society shut forever.

Situation in Contemporary India Studies done among FSWs recently in a few large Indian cities indicate a rapidly rising prevalence of HIV infection among them. The infection transmitted to them by clients get passed on to non-infected clients who again may pass it on to their wives and other sexual partners. About 20 to 40 per cent of infected women are likely to give birth to infected babies. Apparently, FSWs and their clients pose a serious threat to the spread of HIV infection in India. In view of this, several government and non-government agencies have started intervention programmes among FSWs, but these programmes are often based on inadequate knowledge about the attitude, perceptions, sexual behaviour and social environment of FSWs and their clients.

How many FSWs are there in India? It is impossible to answer this question even very roughly. Some estimates have been made of FSWs living in designated red light areas of a few large cities but there are FSWs in all cities, towns and also in many villages. Very often they do not live in identifiable geographical areas. For example, Bombay, Calcutta and Delhi have more or less demarcated red light areas but in Madras no such areas can be identified. Also, many FSWs do not depend wholly on sex work as a profession and are not known in the neighbourhood and Sexual Behaviour and AIDS in India 519 family as such. So estimates of FSWs in cities and other locations are nothing but wild guesses. Some authors have, however, ventured to make some guesses from their own experience. For example, Gilada (1985) provides the following estimates for a few cities: Bombay (1,00,000), Calcutta (1,00,000), Delhi (40,000), Pune (40,000) and Nagpur (13,000). The figures are overestimates according to some investigators with experience of working with FSWs in those cities but they are underestimates compared to those made by the Bharatiya Patita Uddhar Sabha (BPUS), a voluntary agency dedicated to the welfare of FSWs. According to BPUS there are 8.7 million FSWs living in 87,000 kothas (brothels) in addition to 7.5 million call-girls in India (Telegraph, 1992). The current knowledge about FSWs in India is derived mostly from studies done in the red light areas of three large cities. Presented below are some salient findings from studies conducted in Bombay and Calcutta, followed by the available information about call-girls.

Bombay In the early 1960s, Punekar and Rao (1962) interviewed 425 FSWs in a few "tolerated" areas of Bombay. They belonged to two different categories: (i) regular "prostitutes" (350); and (ii) "mistresses" (75). The average income of "prostitutes" was very low (monthly Rs. 51 -100). They had to give 50 per cent of their income to brothel-keepers (gharwalis) and used to remit one-third of their income to their families at home. On the average, a FSW did not have more than three clients per day at the rate of Rs. 1-2 per customer. A large majority of them were indifferent to the client's age but some discouraged young boys. Thirty-six per cent of them suffered from one or more STDs. About one-quarter of them were careful about entertaining "healthy" clients only by turning down those who were found to have visible symptoms of genital illness on prior observation by themselves or brothel- keepers. Thirty-seven out of 75 "mistresses" interviewed were "kept" who de­ pended on one paramour at a time and the remaining 38 were professional singers and dancers. Their income was higher and housing condition better. The majority of their clients were businessmen. Although most women in both categories had low income and lived in an unhealthy environment, only 10 per cent of the total sample were willing to give up their current profession for a respectable job because they liked "this free life". In general, they had friendly relations with brothel-keepers. About half of them maintained cordial relationship with their families.

In a survey of 255 FSWs in a red light area of Bombay covering a period of two years (in the mid 1980s) it was found that their average monthly income was Rs. 100 to Rs. 200 which represents only 20 per cent of the total money they charged from their clients (Gilada, 1985). The remaining 80 per cent was shared by brothel-owners, financiers, pimps and police. They entertained, on the average, four clients per day. Very often 10 to 12 FSWs stayed in one room (approximately 10' x 12') and got their daily food from filthy cafeterias or vendors. Local traders exploited them by selling essential goods at twice the usual price. Laboratory investigations showed that 90 per cent had demonstrable STDs. The prevalence of other diseases such as tuberculosis, chronic pelvic infection, anaemia, scabies and parasite infestation was also high. Most of the local medical practitioners were quacks who dispensed exotic and debilitating remedies at high cost and performed illegal 520 Moni Nag at great risk of serious injury and life. A substantial proportion of the FSWs were from Nepal from where an estimated number of 1,00,000 women (majority of them minor) are brought to India annually for the purpose of prostitution (Gilada, no date). Some of the FSWs were originally devadasis and some were forced into prostitution after being victims of incest (8 per cent) and rape (5-6 per cent). About one-fifth of the FSWs were minor and about one-quarter of them were abducted for the purpose of prostitution. Daughters of FSWs very often became FSWs them­ selves; sons often tended to become pimps.

Calcutta In a survey conducted in 1987 among 6,698 FSWs living in 412 brothel houses of 8 red light areas of Calcutta it was found that the average number of clients per worker per day was 2.7 and the rates for both "short-time" and "night" visits varied considerably in various areas (Ghosh and Das, 1990). The average rate for "short-time" visits ranged from Rs. 10 in Tollygunj to Rs. 35 in Sonagachi. The corresponding rate for night visits ranged from Rs. 35 to Rs. 95. On some assump­ tions regarding the number of rooms in the red light and other areas of Calcutta used for prostitution, and the average income generated from those rooms, Ghosh and Das estimate that the total income generated annually in Calcutta city from organ­ ised sex industry is about Rs. 30 crores (US$15 million). Assuming further that there are about 12,000 FSWs in Calcutta, the income generated per worker per month is approximately Rs. 2,200. It is estimated that about Rs. 20 crores (two-thirds) of the total income generated by FSWs are shared by pimps, house-owners, matrons and others associated with the sex industry. About 37 per cent of FSWs reported that they were either forced by family members and others to take up this profession or were betrayed by someone with false promises of a job. A majority of them (59 per cent) were abandoned by their husbands and 13 percent were widows. A significant proportion of them (30 per cent) were domestic helpers before becoming sex workers. The origin of almost one-quarter of FSWs is in Murshidabad district.

Call-girls The term call-girl is typically applied to a FSW who does not carry out her trade at the place where she lives but at a hotel or the residence of her client. Usually call-girls are more qualified and attractive than FSWs living in brothels and are often engaged in some other profession. Their rates are, on the average, higher and they are not as choiceless regarding their clients as the FSWs in brothels. Appointments with their clients are usually made through brokers or agents who have to be discreet in their looks and behaviour in order to maintain secrecy. Perhaps the only study so far on call-girls in India is the one conducted by Promilla Kapur in Delhi, Bombay and Calcutta. Her book entitled The Life and World of Call Girls in India (1978) was sold widely in India. Her academic credibility as a professor of sociology in Delhi University at the time of the study helped her to get access to the secretive networks of call-girls in the three large cities and make repeated interviews with 150 call-girls and informed discussions with 20 clients and 10 "madams" (usually ex-call-girls). Nearly 80 per cent of the clients were married and some of them were in coveted professional fields. The earnings of call-girls ranged Sexual Behaviour and AIDS in India 521 from Rs. 50 to 500 per hour and Rs. 400 to 10,000 per night. They tried to take good care of their health by visiting physicians whenever necessary. Forty per cent of them reported STDs at any time and 35 per cent had induced abortions. Many of them wanted their clients to use a condom ("rubber sheath") for avoiding STDs and conception but most clients did not like to do so. They were often entertained with alcohol and meals by their clients. A large proportion of clients preferred penile-oral sex to vaginal intercourse and wanted to discuss sex in vulgar language. Some clients wanted vaginal-oral sex.

Laws Regarding Prostitution and AIDS The current legal position regarding prostitution in India is represented by two Acts — Suppression of Immoral Traffic in Women and Girls Act (SITA), 1956; and Immoral Traffic (Prevention) Act (ITPA), 1986. The stated objective of the SITA (1956) was "not abolition of prostitutes and prostitution as such and to make it per se a criminal offence or punish a person because one prostitutes oneself" but "to inhibit or abolish commercialised vice, namely the traffic in persons for the purpose of prostitution as an organised means of living". Prostitution was defined as the act of a female who offers her body for promiscuous sexual intercourse for hire, whether in money or kind (Agnes, 1992; Bhandari et al., 1990: 45-50).

One underlying assumption in the SITA is that prostitution is a "necessary evil" which provides an outlet for "uncontrollable" male sexuality; so it should be tolerated but the rest of the society should be protected from women indulging in prostitution. Under this assumption the Act prohibits a prostitute from public places and forces her to work in certain areas known as red light areas, thereby exposing her to exploitation by house-owners, madams, pimps, tradesman and policemen besides the clients who enjoy greater opportunities for choice and bargaining. One of the most abused parts of the Act is the section 8 which makes punishable the act of soliciting for the purpose of prostitution. This section provides an unexplained on grounds of sex. While a woman soliciting for prostitution can be imprisoned for a term extending up to one year, a man (tout or pimp) can be imprisoned for a maximum term of three months for the same offence. In reality, men are rarely punished at all. Though the SITA did not aim to punish prostitutes for prostitution, it gave enough powers to police and other government agencies to terrorise, harass and financially exploit a prostitute. The ITPA passed in 1986 can be considered as an amendment of the SITA (1956). The ITPA recognises that children or even men can be sexually abused and exploited for commercial pur­ poses. It also seeks to plug the loopholes provided to homeowners and tenants to escape punishment for brothel-keeping under the defence of "lack of knowledge". The main thrust of the ITPA is enhancement of punishment and creation of new categories of offenses.

There are two provisions in the ITPA which might marginally benefit a prostitute: (i) it recognises the abuse of power by the police during raids and prohibits male police officers from making a search unless accompanied by two female police officers; and (ii) it seeks to draw women away from prostitution through their rehabilitation in Protective Homes which should have appropriate technically qualified persons, equipment and other facilities. The Act also mandates that Protective Homes should 522 Moni Nag prepare women for gainful employment and get them employed. However, a recent review of the condition in a well-known Protective Home in Delhi by a panel constituted by the Supreme Court found the inmate women in appalling diet and clothes and deprived of any vocational training and rehabilitation. The well-publi­ cised recent "rescue operation" of the Tamil women from the brothels in Bombay by Tamil Nadu government, resulting in their illegal detention and miserable life for a long time in an open-air prison under construction near Madras is an example of serious drawbacks in government rehabilitation programmes.

There is no legislation in India as yet regarding AIDS. A bill called AIDS Prevention, 1989 was introduced in the Rajya Sabha in August 1989 but because of strong opposition by a few activist groups it is now being reviewed by a Joint Parliamentary Committee (Bhandari et al., 1990). The main argument against it was that it gave government and health authorities sweeping powers to infringe upon the liberties of private citizens without any rational link to preventing the spread of HIV infection or treating the infected persons. For example, one section of the bill allowed for forcible testing of those suspected to be at greater risk of being infected with HIV, that is, those belonging to "high-risk" groups for AIDS, namely, FSWs, intravenous drug users, and professional blood donors. Another section gave the health authorities sweeping powers to "take such other precautionary steps to prevent the spread of HIV infection as it may deem necessary". The authorities could take such steps on the basis of information furnished by medical practitioners or "from any other source". Thus an individual, particularly if (s)he belongs to "high-risk" groups, already suffering from social ostracism, was left with almost no recourse to justice if the provisions of the bill were misused against her/him.

Although there are no legal provisions for involuntary HIV testing of individuals belonging to "high-risk" groups and for isolating them in detention homes or other places, such actions are reportedly not uncommon in India. One such well-publicised incident occurred in Madras in 1990 (Bhandari et al., 1990). Four FSWs, after completion of their periods of sentence in a government vigilance home under the ITPA of 1986, were continued to be held under detention on the ground that they were HIV positive. A petition was filed in the for their release from illegal detention by a journalist, Ms. Shyamala Natraj. The vigilance home authorities defended themselves by arguing that the women got themselves volun­ tarily admitted in the home for medical check-up and treatment. However, the court ruled that the women were not in the vigilance home with their consent and ordered their release. This is a hopeful sign that any further bill introduced in or Rajya Sabha regarding prevention of AIDS will be more sensitive to the plight of FSWs and other "high risk" groups.

Homosexuality It is not easy to define homosexuality. In a simple sense, a homosexual male or female is one who engages in a sexual act with a person of the same sex. But what kind of act should be considered as a sexual act for such a definition? Holding hands? Hugging? Lip kissing? Tongue kissing? Mutual masturbation? Fellatio? Cunnilingus? Anal intercourse? Should a person be labelled homosexual if s(he) engaged in such act/acts only once or rarely during one's childhood? Should a Sexual Behaviour and AIDS in India 523 person be labelled homosexual if s(he) feels sexually attracted towards a person of the same sex but never engaged herself/himself in any of the above acts with a person of the same sex? Alternatively, should a person be labelled as such if (s)he never felt sexually attracted towards a person of the same sex but had to engage herself/himself in any of these acts with a person of the same sex for economic or other reasons? As will be indicated in the following text, although it is difficult to identify a woman or man as absolutely heterosexual or homosexual, for practical purposes it is possible to identify her/his position roughly in a heterosexual-homo­ sexual scale. The word in vogue in English for anything homosexual is "gay". Both male homo­ sexuals and female homosexuals () are referred to as "gays". A homosex­ ual bar is a "gay" bar and the homosexual world the "gay" world. Something or someone heterosexual is "straight" (Karlen, 1971: 307) The word "gay" antedates "homosexual" by several centuries and originally referred to sexual looseness, and was used in reference to FSWs or the lifestyle of men who resorted to them (ABVA, 1991: 18-19). Nowadays, it usually refers to persons whose predominant erotic inclination is towards their own sex whether or not they engage themselves in homosexual behaviour. It also connotes both a sensibility and a political identity instead of merely sexual interest in a person of the same sex. Since this paper is primarily concerned with overt sexual behaviour as a possible transmitter of HIV infection, it seems preferable to use the terms male homosexual and female homosexual rather than "gay".

Situation in Other Countries The complexities involved in labelling a person as homosexual or heterosexual are well-reflected in the findings of the two oft cited reports by Kinsey et al. (1948; 1953) on the sexual behaviour of Cancasian males and females in the United States of America. For example, the sexual history of 4,275 males (15-55 years) interviewed during 1938-1947 revealed that 4 per cent of them had exclusively overt homosexual experience (to the point of orgasm) during their adult life and that only 50 per cent were exclusively heterosexual. The proportion of males who were exclusively homosexual for at least three years during their adult life was 8 per cent; 37 per cent had at least some overt homosexual experience as an adult. About 60 per cent of males engaged themselves in some kind of homosexual activity during their pre- adolescent period (Kinsey et al., 1948: 650-670). These findings led Kinsey et al. to emphasise the continuity of gradation between exclusively homosexual to exclu­ sively heterosexual histories and to develop a six-point scale based on the relative amount of homosexual and heterosexual experience in each history (Kinsey et al., 1948).

The initial spread of HIV epidemic in the USA and a few other western countries was first identified among men who had sex with other men (Turner et al., 1989: 128-129). The clustering of AIDS cases among male homosexuals indicated that the sexual behaviour was at least a principal mode of transmission of AIDS. In order to determine the specific aspects of sexual behaviour responsible for transmitting and promoting AIDS, more than 15 major studies were initiated between 1982 and 1984 in San Francisco, New York, and other cities in the USA. The emphasis on 524 Moni Nag the association of being sick with AIDS or showing signs of immune deficiency with the extremely large number of sexual partners and evidence of drug use among urban homosexual men in the interim reports of some of these studies led to an unfortunate stereotype of homosexual men with AIDS. This stereotype, quickly picked up by popular media, made it appear that the disease afflicted only "reckless" male homosexuals. Prior to the discovery of HIV and of "acquired immune deficiency syndrome" the disease was often referred to as the "gay-related immune deficiency" or GRID, "gay plague" and "gay cancer". The studies conducted subsequent to the discovery of HIV, which focused on specific risky behaviours rather than on the risk group, showed, however, that the risk of HIV infection is greatest for persons who engage in unprotected passive (receptive) anal intercourse. These also showed that the risk of infection is less for partners who engage in active (insertive) anal intercourse and even lower for oral passive intercourse. The risk of HIV infection among highly sexually active male homosexuals decreases significantly with the cessation of receptive anal inter­ course (Turner et al., 1989). A few recent studies have demonstrated that the risk of HIV transmission from infected male to female is higher in anal intercourse than in vaginal intercourse (ESG-HTH, 1992). It can be reasonably presumed that the practice of anal inter­ course is significantly higher among male homosexual partners than among hetero­ sexual partners, thus exposing the former to a higher risk of HIV transmission. So in the context of AIDS prevention in India, a better understanding of the pattern of sexual behaviour of homosexual males deserves priority.

Historical Evidence in India Homosexuality was recognised in ancient India. Vatsyayana's Kama Sutra refers to it in connection with the practice of auparishtaka (oral sex) by eunuchs with their male patrons, by male servants with their masters, by some men who know each other well and also by women of the harem among themselves "when they felt amorous" (Burton and Arbuthnot, 1993: 62-65). Lesbian acts are depicted in the erotic sculptures of medieval Hindu temples (Lal 1966: plates 67 and 68). The representation of the Hindu god Siva as ardha-narishwara (half-female and half- male) in ancient Hindu texts and the Vaishnavic notion that a male body contains Radha or female element (Dimock, 1966) can be interpreted as a recognition of the modern concept of sexual dualism, that is, the universal presence of a homosexual component which varies qualitatively in different individuals (Jung, 1958). During the Muslim rule in India homosexuality entered Indian court life. Some Muslim rulers are reported to have maintained harems of young boys. The Koran and early Islamic religious writings display mildly negative attitude towards homosexuality but in Islamic Sufi literature homosexual eroticism was a metaphorical expression of the spiritual relationship between god and man (ABVA, 1991: 55-56). During the British rule a law was passed making the act of sodomy illegal but not homosexuality as such. of the Indian Penal Code (IPC) enacted in 1861 has the following provisions: "OF UNNATURAL OFFENSES: whoever voluntarily has carnal intercourse against the order of nature with any man, woman or animal, Sexual Behaviour and AIDS in India 525 shall be punished with imprisonment for life or imprisonment of either description for a term which may extend to ten years and shall be liable to fine" (cited in Bhat, 1990). Anal intercourse between man and man or between man and woman (sodomy) and sexual intercourse by a human being with a lower animal (bestiality) are covered under this section. In Independent India, the Section 377 of the IPC is still in force. Section 13 of the Hindu Marriage Act, 1955, has made a further provision by which a wife can apply for annulment of marriage if the husband has been guilty of sodomy or bestiality. Lesbianism, cunnilingus or fellatio between persons of the same or of the opposite sex are not unpunishable under Section 377 of IPC. The homosexual activists in India think that because of the existence of this law, male homosexuals are "subjected to systematic harassment, blackmail and extortion at the hand of enforcement agencies and the public" (ABVA, 1991: 32).

Contemporary Situation in India

Very little is known about the current practice of male or female . Rudimentary findings from a few studies conducted recently are stated below.

Out of 1,424 men (primarily executives and highly educated businessmen) who responded to the Debonair magazine questionnaire survey in 1991, 424 (37 per cent) reported homosexual relationship (Savara and Sridhar, 1992). Twelve percent of unmarried men and 8 per cent of married men reported that their first sexual experience was with another man and most of them (82 per cent) had it before they were 20 years of age. About two-fifths of the respondents — both unmarried and married — had homosexual experience with one or two persons while over a fifth had such experience with more than 10 persons. Only 21 per cent of respondents reported to have used condoms in their homosexual acts. The survey did not yield data regarding the frequency and nature of homosexual relationship the respon­ dents had at the time of survey.

Truck drivers in India (all male) are well-known to have multiple sexual relationship not only with female sex workers but also with other men, particularly with young boys, who accompany them in long highway drives as helpers. In a questionnaire survey of 506 truck drivers entering north-eastern states of India through , 15 per cent admitted previous homosexual experience (Ahmed, 1992). None of them used condoms for any kind of sexual act. In another questionnaire survey of 200 truck drivers in Delhi, 5 per cent reported themselves as bisexual (Singh et al., 1992).

In a study of 2,293 male patients in the Institute of Venerology (Madras) done during 1990-1992, 73 (3 per cent) were homosexuals who earned their living as dancers and/or sex workers (Parasuraman et al., 1992). Most of them belonged to the age group 21-30 years and took both active and passive roles in unprotected anal and oral intercourse. They also entertained their clients by masturbation. They acquired their sexual knowledge from friends and hijras. Sixty-two per cent of the study population had sexually transmitted diseases (mainly syphilis). Elisa test among 73 homosexuals found 4.(5 per cent) of them HIV-positive.

The proportion of women reporting lesbian sexual relationship in the Savvy maga­ zine questionnaire survey conducted in 1992 was less than that of men reporting 526 Moni Nag sexual relationship with other men in the Debonair survey. Out of 362 women respondents, only 31 (9 per cent) said that they even had a sexual relationship with another woman compared to 37 per cent of men respondents of similar class reporting sexual relationship with another man. The first lesbian experience of 77 per cent of women who had such experience was gained before they were 20 years of age. Most of the women (81 per cent) who had lesbian relationship had it with one or two partners. Only 7 per cent had it with more than 7 persons.

Group Action by Homosexuals

Although there was recognition of homosexuality in ancient India, it never attained social approval in any section of the Indian population and it was a taboo subject even for a mention until the panic regarding AIDS reached India. Section 377 of the Indian Penal Code made it virtually illegal. The fear and shame of being detected by family and society often lead many men and women, who feel sexually attracted towards persons of their same sex, to keep their sexual identity to themselves and eventually marry or are married to persons of opposite sex with unhappy conse­ quences for both partners (Kala, 1993). The wide publicity of relatively high preva­ lence of HIV infection among homosexual males in USA and other western countries in the early 1980s helped in generating the popular misconception of AIDS as a gay or male homosexual disease not only in those countries but also in India and other countries.

Although it is acknowledged by Indian medical establishments by now that homo­ sexuality is not a major factor in the rapid spread of HIV infection in India, in popular imagination it is still strongly associated with AIDS. For this reason and also for the reason that there is no official recognition of homosexuality or , several attempts have been made by some Indian men and women who are psychologically oriented towards such varieties of sexuality (and would like to call themselves "gay") to organise themselves as formal groups for social and political purposes (ABVA, 1991: 15-17). The 2nd International Congress on AIDS in Asia and the Pacific held in Delhi in November 1992 gave them an opportunity to meet "gay" leaders from other countries and articulate their problems and demands in the conference itself and also in Indian popular media.

A few newsletters and magazines sponsored by "gay" groups in India and elsewhere have been trying to establish local networks of such groups and provide information of special concern to "gay" people. Among them, Bombay Dost, edited by (an openly "gay" journalist) and others is perhaps known most widely. It received sympathetic coverage in Indian media in 1991 when, after a year of hard struggle as an underground newsletter, it started coming out as a registered magazine with contents both in English and Hindi. From then on, it could legally use the Indian postal system for mailing at reasonable rates and accept advertisement. Its objectives include provision of "a platform for people interested in an alternate sexuality" and "counselling, information and advice in all such areas which are of interest to this alternate sexuality and its safe practice." It makes special efforts to popularise use of condoms among male homosexuals who, as a group, suffer from lack of information about prevention of AIDS and are in great need for peer education. Its success in initiating open discussion on homosexuality in popular Sexual Behaviour and AIDS in India 527

Indian magazines and newspapers is expected to contribute towards removal of some common prejudices against it.

Hijras and Male Sex Workers

Hijras

The commonly used English translation of the Urdu word "hijra", an institutionalised role in India, is eunuch. A less commonly used translation is (hermaphrodite). Eunuch refers to a castrated (emasculated) male and intersex refers to a person whose genitals are ambiguously male-like at birth. Impotence is the force behind both the English words but it is only a necessary and not a sufficient condition for being recognised as hijra in India. According to Nanda (1989: 15), an American anthropologist who has studied Indian hijra communities both extensively and intensively, castration is the dharm (religious obligation) of the hijras. The renunciation of male sexuality through the surgical removal of the organ of male sexuality is at the heart of the hijra social identity. The people whom they entertain or who seek their ritual services in marriage and childbirth ceremonies also do not accept any non-castrated person as hijra.

Hijras live predominantly in north Indian cities where they have greater opportunity to carry on their traditional roles of performing at homes on occasions of male childbirth, weddings and other festivals. Their total population is not known because Indian census does not enumerate them separately. The estimate ranges from 50,000 (India Today, 1982) to 500,000 (Tribune, 1983) in the early 1980s. Tradition­ ally, hijras earn their living by receiving payment for their performance and begging. They carry the infant and hold his genital as they dance. Because of their identifi­ cation with Bahuchara Mata, one of the many mother goddesses worshipped in India, they are believed by some to have the power to confer prosperity and health on the infant and family, as well as the power to do harm. There are, however, others who ridicule the notion that they have any real power (Nanda, 1986).

There is a widespread belief in India that hijras are intersexed persons claimed or kidnapped by the hijra community as infants and children, but Nanda thinks that the hijra community attracts persons most of whom join voluntarily as teenagers or adults. They include individuals of a wide range of cross-gender characteristics arising from within a psychological or organic conditioning. A recent study of 35 hijras in a Bombay slums revealed, however, that almost all of them were either sold by their poverty-stricken parents or were kidnapped as children (Allahabadia et al., 1992).

Anthropologists who have studied hijra communities in various parts of India generally agree that, in addition to their dependence on the cultural role as performers for means of livelihood, they also engage in sexual activity with men for money or for satisfying their own sexual desires. A few nineteenth century reports also mention kidnapping of small boys by hijras for the purpose of sodomy or prostitution (Bhimbhai, 1901; Faridi, 1899). In a study of hijras in Lucknow city, Sinha (1967) found that although they were pursuing their cultural role as performers, their primary motivation to join the hijra community was to satisfy their own sexual desires. 528 Moni Nag

A study of hijras in Hyderabad indicates that for some of them a period of homosex­ ual activity precedes their joining the hijra community. Hijras' role as transvestite sex workers is emphasised by Freeman (1979) in his report on hijras of Orissa. Extensive studies of hijra communities in Bangalore, Bombay and several north Indian cities by Nanda (1986; 1989) convinced her that "hijras in contemporary India extensively engage in sexual relations with men." The following account of sexual behaviour patterns of the hijras and its conflict with the hijra cultural ideal of is extracted from her writings. Nanda finds confirmation of Sinha's finding that teenage homosexual activity often figures significantly in the lives of many men who join the hijra community. Typically, during their boyhood they like to dress, play and work as girls. In a lower class community, a boy's feminine demeanor is often ridiculed by his peers but also encouraged by some of them who may like him to take the passive role in homosexual activities, possibly with some monetary consideration. When his family members realise his homosexual inclination and activities, they may try to change his attitude and behaviour by scolding him and punishing him in ways which leave him no other alternative but to leave his family and perhaps join a hijra community subsequently.

Two modes of sexual relations are prevalent among hijras. Some of them, perhaps the majority, engage in casual prostitution by offering sexual favours to different men in exchange of money, the amount of which is mutually agreed on a case by case basis. The other mode of hijra sexual relations is "having a husband". It involves a relatively long-term relationship of a hijra with a man. In such a relationship a hijra is very likely to have strong feminine identity and would come closest to what would be called in the West a transsexual or transvestite, that is, a man who feels himself as a "female trapped in a male body". "Having a husband" is the preferred alternative for those hijras who openly engage in sexual relations with men. Some of them are reported to have economically reciprocal and emotionally satisfying relationship with the "husbands". They may live together, sometimes alone, or sometimes with other hijras. Hijras do not characterise their male sexual partners, whether casual or "husbands", as homosexual. One hijra informant who had a "husband" and was somewhat exceptional in taking hormones "to develop a more feminine figure" told Nanda (1986:44): "Those who come to us, they have no desire to go to a man....they come to us for the sake of going to a girl. They prefer us to their wives.... It is God's way because we have to make a living, he made people like this so we can earn." Another hijra explained the attraction of men to hijras on different grounds: "See, there is a proverb, for a normal lady (prostitute) it is four annas and for a hijra it is twelve annas. These men, they come to us to have pleasure on their own terms. They may want to kiss us or do so many things. For instance, the customer will ask us to lift the legs (from a position lying on the back) so that they can do it through the anus. We allow them to do it by the back (anal intercourse), but not very often."

Although many hijras engage themselves in sexual activity, they are aware that sexual activity is offensive to their goddess Bahuchara Mata. Upon formal initiation into the hijra community through the ritual of castration performed by a hijra dai ma (midwife), the novice vows to abstain from sexual relations or to marry. The hijra call the castration operation nirvan — a condition of calm and absence of desire — Sexual Behaviour and AIDS in India 529 which is believed to transform the ordinary, important male to a hijra endowed with Mata's sacred powers. The evidence of castration is a culturally defined "proof" of hijras' renunciation of sex which legitimises their ritual functions in Indian society. When authenticity of hijra performers is challenged by their audience, the former often lift their skirts and show off their genital region. If their genitals have not been removed they may be reviled and driven away as impostors. Hijras who have been castrated deride the "fake" hijras — men who do join their community only to make a living from it or enjoy sexual relation with other men.

Hijra elders, many of whom are heads of households consisting of 5 to 15 hijras, claim that they lock their doors by nine o'clock at night, implying that no sexual activities occur there. In some places where hijra culture is strong, hijras who can support themselves fully through ritual performances may live separately from those who depend partly or fully on prostitution. In other places, more peripheral to the core of hijra culture, including most of south India, there is no such separation. Sexually active hijras admit that hijras usually join the community mainly with the purpose of engaging in sexual relations with other men and claim that the elders who now talk about the hijra ideal of sexual renunciation also engaged themselves in prostitution in their younger days. However, even young hijras who have "hus­ bands" or practice prostitution acknowledge that such behaviour lowers their status in the larger societies and that it is a necessary evil for them. They attribute their increasing dependence on prostitution to the declining demand for their ritual performances and the consequent lowering of their economic status. No study seems to have been done so far in India regarding the techniques of their sexual acts with other men. Perhaps the most commonly used technique is anal intercourse in which they take the passive role and also without using condom. If so, chances of their being infected with HIV and STDs are very high and serious attempts should be made for raising their awareness about AIDS/STD and providing other preventive services. Hijras constitute a marginal group in Indian society which zealously guards its privacy. So special strategies are needed to gain access to them for any intervention programmes.

Male Sex Workers

In addition to the hijras who engage themselves in sexual relations with other men for monetary gains, there are other male sexual workers in India. Journalistic reports indicate that their number is not negligible. The most visible group of male sex workers in India is perhaps the one in the Kamathipura red light area of Bombay which I visited in 1992. A cursory look at some of them standing in front of their houses in 1992 gave me the wrong impression they were women with higher quality clothing and make-ups than those of the neighboring FSWs. I was told by the social worker who was working in the neighborhood for an AIDS prevention project that the male sexual workers had a relatively higher income. It is reported that a large proportion of boys who earn their living apparently by providing massage service in parks, beaches and homes and by providing auxiliary services to highway truck drivers also engage in homosexual relations for monetary gains. In addition, many homeless boys and boys employed in varieties of establishments and firms are reported to be exploited sexually by their male employees and others. 530 Moni Nag

Use of Condoms

Condoms were originally devised and used everywhere primarily as a preventive for sexually transmitted diseases mostly in sexual relations of men with FSWs (Himes, 1960: 186-194). In India, as elsewhere, they are now perceived and used primarily as a contraceptive. Prior to the early 1960s when the Government of India and Family Planning Association of India started the distribution of condoms through their family planning programmes, limited quantities of condoms were available in specialised stores of large cities had to be sold very discreetly. At present, the Government of India runs the largest programme in the world for distribution of condoms (known popularly by the government brand name Nirodh, which means "barrier"). The number of condoms distributed annually through its health and other channels increased from 59 million in 1968-69 to 1,020 million in 1989-90 (India, MHFW 1991: 192-193). A large portion of the condoms distributed by the govern­ ment is free (64 per cent in 1988-89). The government itself recognises, however, that about 50 per cent of the condoms reported to be distributed free are not actually used (Gopalakrishnan, 1992: 34). Various channels through which condoms are distributed currently include the following: Primary Health Centres and Sub-Centres; government hospitals, dispensaries and other facilities; community depot holders (who earn a small income from retailing); and the government's social marketing programme which provides condoms to commercial retailers and voluntary organi­ sations at a subsidised price. The other major sources of condoms in India are Indian private sector companies selling India-made (about 80 million pieces a year) and imported (about 40 million a year) condoms at commercial rate.

Prevalence of Condom Use The proportion of couples in reproductive ages using condoms in India is still not high despite some efforts made recently by the government to shift its family welfare programme emphasis from irreversible methods (sterilisation) to spacing methods. It is, however, higher than the proportion using any other spacing methods [for example, Intra Uterine Device (IUD) and oral pills]. The proportion of condom users increased from 3 per cent in 1970 to only 5 per cent in 1988-89, while the total contraceptive prevalence increased from 14 per cent in 1970 to 43 per cent in 1988-93. For reasons not yet understood, Indian states/union territories vary con­ siderably in their choice of condom as a contraceptive method. For example, while the all India average of condom users among all contraceptive users is 12 percent, the corresponding proportions in , Delhi, Punjab and Uttar Pradesh are as high as 43, 41, 30 and 22 respectively and in Andhra Pradesh and Karnataka as low as 4 per cent in each (Operations Research Group, 1991).

Limited studies done so far among truck drivers, who, as a group, are vulnerable to STDs, indicate generally a very sparse use of condoms by them. None of 506 truck drivers interviewed in Assam reported condom use although 82 per cent of them admitted regular contact with FSWs along the highways and 36 per cent admitted having STD treatment at least once in their life (Ahmed, 1992). Eighty-nine out of 100 truck drivers interviewed near Bangalore in May 1993 reported that they never used condoms because condoms are considered by them as obstacles to pleasure and as a device for (Mani, 1993). One of them said that once a FSW Sexual Behaviour and AIDS in India 531 insisted on the use of condom, as advised by a local NGO volunteer, but he succeeded to have sex with her without a condom by paying Rs. 10 over the usual rate. A survey of 200 truck drivers in Delhi in 1988, however, showed a higher use of condoms. Seventy-eight per cent of them admitted to being heterosexually promiscuous and 28 per cent among them reported use of condoms regularly and 72 per cent only sometimes (Singh et al. 1992).

It is commonly believed that because of women's subordinate role and glorification of women's modesty in Indian tradition, Indian women cannot be realistically expected to take an active role in a sexual relationship and in condom usage (Mane and Maitra, 1992: 67). This is more true for FSWs, who due to severe competition and economic pressure, are left with almost no option to enforce or ensure condom use (Sundararaman et al., 1992) against their clients' reluctance. Studies indeed show that the use of condoms among FSWs is generally very low, despite high prevalence of STDs among them and their desire to avoid pregnancy. For example, even call-girls studied by Kapur (1978:209) in Delhi, Bombay and Calcutta reported that their clients would not agree to use condoms even though they insisted on it. But a few recent studies cited below indicate that with adequate counselling, peer group training and other appropriate strategies, condom use among FSWs can be reasonably increased.

In a survey of 450 FSWs conducted during April-May 1992 in a red light area of Calcutta only 4 per cent reported regular use of condoms, although 50 per cent were using oral pills (Jana, 1992:105). Clinical tests revealed 59 per cent of them positive for VDRL (veneral diseases) and 1 percent positive for HIV (Chakraborthy, 1992). The survey was followed by an intervention project which included diagnosis and treatment of STDs, and IEC (Information, Education and Communication) for behavioural change and promotion of condoms. The project succeeded in increas­ ing the awareness of FSWs regarding STDs and AIDS and increasing the condom use to 60 percent in May 1993 {Indian Express, 1992). By that time, 30,000 condoms were distributed among the FSWs at a price by 24 trained educators who were recruited from FSWs in the area and paid a nominal amount of money for this service. Pimps and madams in the area have been quick to grasp that a FSW free from disease is an asset with a longer healthy life and they themselves are enforcing the use of condoms by clients. Some FSWs have been already refusing to have sex with clients unless they use condoms. ' '

Another project reported to be successful in increasing condom use among FSWs is the one sponsored by the Population Services International (PSI), an Indian voluntary organisation (Gopalakrishnan, 1992). The project, operating among 5,000 FSWs in a red light area of Bombay, has four components:

(1) person-to-person communication with FSWs through communicators recruited from FSWs and trained to handle minor ailments; (2) availability of a doctor to the community for back-up services and referral to hospitals and clinics with established tie-ups; (3) communication with clients through (a) special audio-visual means in local bars, restaurants and cinema halls, (b) posters, stickers, leaflets and hoardings, 532 Moni Nag

(c) a four-hour "record dance show" every evening where a troupe of artists perform a live entertainment-cum-education show on a stage built on a street in the red light area, and (d) distribution of condoms at a price through FSWs and through local bars, restaurants, STD clinics, barber shops and other outlets. In addition, FSWs are sometimes entertained in cinema halls with popular Hindi cinemas (donated by the film industry) which are interrupted at intervals for delivering educational messages.

No assessment in terms of percentage increase in condom use has yet been done but I was told by a PSI personnel in Bombay in July 1993 that 7,000 PSI's Masti brand condoms were being sold per month on the average in the area.

Constraints on the Use of Condoms

The family planning campaign in India during the last three decades has succeeded in making most of its adult population aware of the use of the condom. Its reversibility is an advantageous feature for couples who want to space births rather than terminate their childbearing. Its non-clinical nature makes it free from any side effect and amenable to use without medical help. It protects couples both from unwanted pregnancy and sexually transmitted infection. In spite of these, the proportion of reproductive age couples using condoms in India was 5 per cent in 1988-89 — a proportion higher than in many countries but lower than, for example, in Japan (45 per cent in 1986), and Hong Kong (26 per cent in 1986). The main constraints on the use of condoms in India are:

(i) poor quality, (ii) low effectiveness, (iii) inadequate knowledge about its advantages, (iv) cultural sensitivity, and (v) difficulties of storage and disposal.

These constraints are not necessarily independent of each other.

One common complaint against condoms in India, as elsewhere, is that it reduces the pleasure of sexual intercourse. Interruption in the sex act necessary for the use of condom is a source of displeasure, but its thickness seems to be a more relevant factor. Greater the thickness, less is the feeling of pleasure. Lack of lubrication is also a cause of displeasure for both partners and may cause vaginal irritations in female partners. The Nirodh brand of condoms, the only brand distributed by the Indian government through its various channels until the mid-1980s, had both these weaknesses. A lubricated condom (Nirodh Delux) was launched in a small scale by the government in 1984 and subsequently a few other brands of thinner and better-lubricated Nirodh have been introduced. But for various reasons, better quality Nirodh condoms seem not to have as yet reached a wide section of population, particularly in rural areas.

The quality of the condom, in terms of the presence of tiny holes in it and its proneness to rupture or breakage during use, is an important factor in its effective­ ness for protection against pregnancy and infection. In a study of Nirodh-users in Sexual Behaviour and AIDS in India 533

Rajasthan in the 1970s, about 25 per cent of urban and 16 percent of rural residents reported at least one instance of rupturing of condoms (Bhende, 1975). In an earlier study in Rajasthan, 31 per cent in urban and 13 per cent in rural areas reported rupture (Abhichandaney et al., 1972). In a recent awareness workshop a FSW is reported to have commented that "they often tear off during use" and "nobody is using them" (Telegraph, 1992). Inadequate knowledge about the proper use and storage of condoms in the household also contributes towards its ineffectiveness. Its failure as a contraceptive is often attributed to many couples not using it as regularly as needed, using the same condom more than once, damaging it with long finger nails, withdrawing it only after the penis is flaccid and without holding its rim (Mane and Maitra, 1992: 101). Some couples, while using unlubricated condom, lubricate it with vaseline and various kinds of oils and lotions which cause perforations in it and make it vulnerable to leak and rupture. Because of the lack of space and privacy in Indian homes condoms are often stored under the bed, under the tiles of the humid roof and other similar inappropriate places leading to the deterioration of their quality and effec­ tiveness. Although attempts are being made for wider distribution of better quality condoms, serious efforts in counselling potential condom users in their proper usage and storage still seem to be lacking. One constraint in mitigating this drawback in Indian family welfare programmes is that the grassroots level workers responsible for motivating and counselling couples are mostly female and condom being considered primarily a 'male' method of contraception, women workers are at a special disadvantage in counselling men about it. But the example of a successful family planning project carried out by an NGO in Matlab upazila of Bangladesh indicates that such cultural sensitivities need not stand as a serious impediment to the use of condoms. In that project village-level female workers have been so well-trained in counselling techniques that they demonstrate, without any inhibition, how to use condoms properly to young couples motivated to do so (Nag, 1988).

Cultural sensitivity regarding condoms is higher than other methods like sterilisation, oral pills and lUDs because its use is more directly related to the sexual act. Open display of condoms in pharmacies, stores and clinics and open discussion about it are still avoided as far as possible. Couples using it have to take extra precautions to see that other members of the household do not come across the places where they are stored or disposed of. Buying a condom from a pharmacy or a store or getting it from a clinic is still a matter of great embarrassment for most men and women. Ethno-physiological fear that the condom may get lost inside a woman's body has also been reported.

With impending danger of the AIDS pandemic in India, mainly through unprotected sexual intercourse, an intervention programme for much wider use of condoms than at present, particularly among groups of people, who are vulnerable to AIDS and STDs but not using condoms on a regular basis, is a matter of urgent priority in India. The government has already taken steps to enhance the production of better quality condoms which resist rupture and diminishes the loss of pleasure in sexual inter­ course. More, however, can be done to promote the romantic and pleasure aspects of condoms by taking cues from the packaging and advertising strategies success­ fully adopted for the promotion of commercially manufactured condom brands such 534 Moni Nag as, "Kamasutra" and "Adam". These brands emphasise, in their visually attractive advertisements, the sensuous aspect of the condom rather than its pregnancy and infection controlling aspects. It should, however, be noted that these high-priced brands are meant for use by relatively affluent couples who are already aware of the protective aspects of condoms. For common people in India the role of condom as a principal means for protection against STDs need to be specially publicised because they are mostly aware of its role as a contraceptive only.

Providing better education and counselling to people regarding proper usage of condoms and making it more easily available impinge on a cultural domain but cultural change through appropriate programmatic actions are not always unfeasi­ ble. Cultural sensitivity to condoms can be mitigated by creatively using traditional and modem media to propagate educational messages with empathy, humour and respect for human dignity. Perhaps condom-blowing contests in public places or training FSWs in skilfully rolling the condom during oral sex (reported to be effective in Thailand) are not feasible in the Indian situation, but the strategies like those adopted by the AIDS Research Foundation in India (ARFI), Madras — to give as a gift to truck drivers a key chain with a condom attached to it for initiating a discussion on condoms with them, and by the Population Services International (PSI), Bombay to organise on the streets of a red light area a disco performance loaded with condom promotion, seem to have some success. Although India has not as yet reached the age of coin-operated vending machines, its introduction in strategic places for distribution of condoms along with other common items like pan-parag (spiced betel nuts), combs, soaps and so on, deserves consideration.

Sexual Abstinence

A Virtue in Indian Tradition

Abstinence from sex is considered as a virtue in Hindu religious scriptures. Accord­ ing to the Upanishads, the philosophical treatise elaborating the earlier Vedas, one may "realise the self" by practising asceticism (tapas), which includes total absti­ nence from sex as an essential element. Sexual excitement represents a threat against which an ascetic (yogi) is advised to be always on guard. Ironically, one of the rewards of abstinence practiced rigorously as a mortal is the prospect of pleasure with nymphs (apsaras) in heaven after death (O'Flaherty, 1973: 64). A funeral hymn in implores the funeral pyre not to burn the phallus of the deceased for this reason.

Hindu epics enjoin husbands and wives to have sexual intercourse for begetting children at specific periods of women's menstrual cycles when they are believed to be particularly fecund but to abstain from sex at other times. Ritu, the period immediately following the onset of menstruation, is considered most propitious for conception. The neglect by a man to approach his wife at the ritu time is listed in Mahabharata as one of the horrible sins punished with torments in the "other world". But it also enjoins, "let him call his wife only at the time of ritu", because copulation outside the ritu is a sin equivalent to that of killing a cow. Overindulgence in sex was discouraged in ancient India (O'Flaherty, 1973). We read, for instance of Vicitravirya Sexual Behaviour and AIDS in India 535

and Vyushitacva of Mahabharata, princes who, owing to an overindulgence of sex, fell victim to consumption and early death (Meyer, 1953). The traditional aspiration of sublimating sexuality into spirituality through abstinence in Hindu culture has influenced Hindu thoughts and actions throughout history. Only small sections of contemporary Hindus may practice total abstinence from sex for spiritual gain, but the theory of sublimation is well-known and subscribed to by a vast majority of them, although in varied forms and strengths in different caste and class groups (Kakar, 1989: 118-119). In its most popular and simplistic version, the theory states that virya — a word that stands for both vigour and semen — is the source of physical as well as spiritual strength and that the loss of virya through sexual act or imagery is harmful both physically and spiritually. Some popular versions of the theory elaborate further that virya can either move downward in sexual intercourse and emitted in its gross physical form as semen or it can move upward through spinal cord to the brain in its subtle form known as ojas. The downward movement in the form of semen, caused by sexual passion, is regarded as a debilitating waste of vitality and energy. Through the observance of brahmacharya — the total abstinence from sex in thought, word and deed — semen can be converted into ojas and moved upward to the brain. In that case, it becomes a source of physical vitality and spiritual strength. Through akhanda (unbroken) brahmacharya for a long period one can spontaneously attain moksha (release from the cycles of birth and death).

According to Hindu metaphysical physiology, food is converted into semen by successive transformations through blood, flesh, fat, bone and marrow (Kakar, 1989). A few common assumptions are: (i) 40 drops of blood produce one drop of semen; (ii) each involves a loss of half an ounce of semen which requires consumption of 60 pounds of food; and (iii) each copulation is equivalent to an energy expenditure of 24 hours of concentrated mental activity or 72 hours of hard physical labour.

Beliefs and Practices in Contemporary India was a strong advocate of total sexual abstinence except for begetting children. His following statement reiterates the traditional notion about loss of energy through loss of semen (Ghandhi, 1943: 71):

Once the idea, that the only and grand function of the sexual organ is generation, possesses men and women, union for any other purpose they will hold as criminal waste of vital fluid, and consequent excitement caused to men and women as an equally criminal waste of precious energy. It is now easy to understand why the scientists of old have put such great value upon the vital fluid and why they have insisted upon its strong transmutation into the highest form of energy for the benefit of society.

Throughout his life Gandhi agonised obsessively over his genital desire (Ibid: 93-106). According to him, desire for sexual pleasure, "whether its object is one's wife or some other woman", is "impure" and "poisonous". Even involuntary dis­ charge of semen during sleep was attributed by him to the presence of "impure" desire in mind. He was so concerned about such events that even when he was 536 Moni Nag about 60 years old and in the midst of his intense political activity, he wrote in response to an unknown young man's letter: "I had two involuntary discharges twice during the last two weeks" and as an expression of guilt feeling added further: "What is present in the body like some hidden poison, always makes its way, even forcibly sometimes". In another letter addressed to one of his disciples when he was 66 years old he wrote: "If my brahmacharya had been without shedding of semen then I would have been able to present many more things to the world".

Anthropological studies done in India rarely deal with the sexual aspect of life. One exception is the study conducted by Carstairs (1967) of a high caste Hindu community in 1951-52 in a Rajasthan village. Carstair's analysis of 46 case studies and his experience of medical practice in the village led him to conclude that one principal concern among the villagers about their bodily functions was the need to restrain one's instinctual impulses, particularly sexual impulses, whose gratification was believed to lead to physical and spiritual degeneration. It found expression in the complex of ideas relating to the creation, preservation and loss of semen.

It was common knowledge in the village that "it takes forty days, and forty drops of blood, to make one drop of semen", but the process of the transformation from food to semen was described variously by informants. Also, everyone agreed that "semen is ultimately stored in a reservoir in the head, whose capacity is twenty tolas (6.8 ounces)" and that a man who possesses a store of rich and viscous semen "glows with radiant health". The dilemma of losing strength through every sexual orgasm and, at the same time, fulfilling the obligation to procreate made men feel the need to restrict sex to a defined number of days. Many seemingly healthy persons were preoccupied with real or imagined spermatorrhea (Jiryan). Carstairs (1967:83-87) claims that this preoccupation with jiryan is the commonest expression of anxiety neuroses among the Hindu communities of Rajasthan and perhaps elsewhere in India as well. He thinks that this is a defence mechanism against people's anxiety when they fail to confine their sensuality within their perceived "proper measure" (niyamse).

Hindu law books and Puranas prohibit sexual relations on specific days related to the phases of the moon and the sun every month. For example, Vishnu Purana states (Meyer, 1930: 245):

The fourteenth and eighth days of the half-moon, the day of the new moon, also the day of the full moon and also the day when the sun comes into a new house of the zodiac, these are the Parvan days, oh, ruler of the princes. The man who on these Parvan days partakes of oil, flesh and woman goes after death to hell, where dung and urine must be his food.

The fragmentary evidence available for contemporary Hindus indicates that the customary days in which sexual relations are prohibited are not always necessarily to the phases of the moon or sun; they may include ritual/festival days or any specific days of the week (Nag, 1972: 236-237). in a study of the Ramnagaram area of rural Mysore in the early 1950s, Chandrasekaran (1952: 77-78) found that about 50 per cent of the persons interviewed reported avoidance of coitus on well-known festival days, specific days related to the phase of the moon and of the week (Sunday, Sexual Behaviour and AIDS in India 537

Monday and Saturday), days of shaving and days of sowing in the field. The median value of the days of avoidance in Ramnagaram was 24 days per year. In a rural area of West Bengal the number of such days was estimated as 80 (Nag, 1967: 161). However, there are discrepancies between the ideally sanctioned and actually observed days of ritual abstinence. Also, there are considerable variations among different regions, castes, classes and generations. The perception about the value of sexual abstinence in Hindu culture has always been quite different from that in Western culture. Although according to the Catholic viewpoint, "to sacrifice sex privileges by a celibate life is superior to the use of generative function if it is undertaken for the purpose of freeing oneself for an even nobler service of God" (Clemens, 1961: 236), many Western psychologists and sexologists consider prolonged abstinence detrimental to mental and physical health (Biegle, 1964; Robinson, 1930). According to them for majority of both men and women sexual abstinence is undesirable. For men it may cause night emission, impotence, congested prostrate, premature ejaculation, weak erection and insom­ nia; for women it may cause chlorosis, dysmenorrhoea, shrinking of breast and congestion of ovaries. Freud (1924:219-220) was convinced that "abstinence is the source of various ills besides neuroses" but he also viewed the attempts towards sublimation of "genital libido" through abstinence in relative terms: The proportion of possible sublimation and of unavoidable sexual activity varies considerably not only to the individuals but to the careers they follow. Abstinence is hardly thinkable for young artists while young scientists who abstain are not a rarity. The abstinent scientist can devote more of his energy to his studies; sexual experiences, on the contrary, act as a stimulant to artistic activity. To my knowledge, contemporary Indian literature on sex contains hardly any reference to the negative effect of sexual abstinence on human body and mind. On the other hand, despite a widespread display of sexual innuendos in Indian movies and media advertisements, the positive value of abstinence is perhaps still deeply ingrained in most sections of Indian population. The feelings of anxiety and guilt regarding masturbation revealed in a large proportion of letters from young men in response to sex education articles published in popular youth magazines support this conjecture. Similar magazines in Western countries rarely have such letters. On the contrary, the current trend is to criticise the idea of preaching sexual abstinence to unmarried boys and girls in the context of prevention of AIDS and . The dominant view at least in metropolitan areas of USA and few other western countries affected severely by the AIDS pandemic is that it is useless to stress sexual abstinence in sex education curricula of schools because it will simply turn off the students, a large proportion of whom are already engaged in sexual relations; so it is better to see that condoms become more easily available to them by making them accessible to them within schools. In the Indian cultural context and in the context of rapid spread of HIV/STD infection, it seems appropriate to emphasise abstinence from premarital and multiple sexual relationship as a viable option for protection from infection. 538 Moni Nag

Priorities of Research on Sexual Behaviour

Sexuality and sexual behaviour encompass a vast area of human nature and behaviour. Its wide range and enormous complexities are reflected in The Encyclo­ pedia of Sexual Behaviour (1961) edited by Albert Ellis and Albert Abarbanel which contains 111 articles, many of them written by internationally recognised authorities of the day. The research orientation of the articles is more biomedical and psycho­ logical than behavioural. The studies on behavioural aspects of sex conducted since then, mostly in western countries, has identified new dimensions of sexual behavior which need further elaboration from both theoretical and applied perspectives.

This paper deals with quite a narrow range of aspects of sexual behaviour which are particularly relevant to AIDS/STD. For example, masturbation, which seems to be widely practiced and is a source of considerable anxiety for many young men in India is not included as a topic in it because of its apparent lack of relevance for AIDS/STD. Similarly, dimensions of sexuality, which is a more comprehensive concept that encompasses the physical capacity for sexual arousal and gender identities (Dixon-Mueller, 1992), are not covered here.

A few studies sponsored by National AIDS Control Organisation (India NACO, 1993: 46-48) in the early 1993 mainly in large Indian cities with the objective of mapping and assessing the magnitude of a range of AIDS-related high-risk behaviour have provisions for collecting sexual behaviour information. Since the primary purpose of the studies is urgent "fact-finding for advocacy and planning of interventions" and they are expected to be completed within one year, they do not admittedly "aim to be in-depth, analytical or explanatory". Although they are worthwhile in view of the urgent need for launching intervention programmes among groups which are at high risk of transmitting HIV through sexual relations, blood transfusion and intravenous injection of drugs, these studies are not expected to yield adequate information on sexual behaviour.

In order to collect more reliable and useful information on a very sensitive and personal topic like sexual behaviour, it is necessary to use quasi-anthropological techniques which can yield in-depth data of both a quantitative and qualitative nature. Since the information available on sexual behaviour in India is so scanty, the studies should not be confined only to the groups which are currently assumed to be in high risk for AIDS/STD. Perhaps common people in India are not as reluctant or inhibited to talk about sex as is often assumed from the perspective of overt middle class sexual morality, but, at the same time, they are not expected to share their personal behaviour and attitudes regarding sex to an interviewer who has not been able to create the necessary rapport with them and who is not skilled enough to ask questions in a way acceptable to them. One main reason why Carstairs (1967) was able to collect interesting information on sexual behaviour of high caste men of a Rajasthan village was that as a physician he was able to create sufficient rapport with them to discuss sex with reference to their health problems. It seems that in India action-cum-research on including STD and AIDS would provide an appropriate context for eliciting reliable information on sexual behaviour.

On the basis of the review of studies discussed in preceding pages and in consid­ eration of the limited amount of skilled human resources and money available for Sexual Behaviour and AIDS in India 539 research, I would suggest the following areas as deserving priority in terms of relevance for AIDS/STD prevention programme: Frequent Clients of Female Sex Workers (FSWs): Changes in sexual behaviour of FSWs in favour of AIDS/STD prevention (particularly in use of condoms and avoidance of anal intercourse) depend quite heavily on changes in sexual behaviour and attitude of their clients. Paucity of information on them is a serious constraint in making them adequately aware of the dangers of AIDS/STD infection and the means of avoiding it. It is indeed difficult to reach them for study and educational purposes, but a few exploratory studies in Bombay and Madras have shown that there is scope for devising innovative and effective approaches for the purpose. Studies done so far indicate that the categories of men who frequent the FSWs include the following: migrant labourers who are unmarried or living away from their spouses, highway truck drivers and their assistants, college students, out-of-school unmarried young men and STD clinic patients.

FSWs Living Outside Well-known Red Light Areas: In India there are perhaps more numerous FSWs (including call-girls and devadasis) living outside the well-known red light areas than inside those areas. Thanks to some awareness campaigns and intervention projects already started in the red light areas of a few cities, perhaps majority of FSWs, pimps, and madams in those areas are at least conscious of the potential threat from AIDS, although they are often unable to take preventive action even if motivated to do so. There are also reports of emergence of FSW or ex-FSW leaders (although still rare) powerful enough to lead group actions resisting clients unwilling to use condoms. Such actions are not feasible in brothels outside the red light areas because of the difficulties of reaching the FSWs living in them and their clients for study and educational purposes. In view of the magnitude of potential risk of HIV transmission through them, studies among them deserve priority.

Sexually Exploited Groups: These groups, which are highly vulnerable to HIV/STD infection and who perhaps have even less control over their sexual relations than FSWs, include homeless (street) children, poor children and women employed in organised and non-organised sectors and victims of rape. Homeless (often orphan) boys and girls who live a hand-to-mouth existence by working as ragpickers and in whatever odd jobs available to them during daytime, and sleep at night in public places like streets, parks and railway stations in cities, are easy victims of sexual exploitation by many men including those who have some control over these public places. The exploiters are likely to belong to high-risk groups regarding HIV/STD infection. Thousands of children who work for long hours under pitiable conditions in small establishments (such as non-family tea-shops and carpet-making firms) as well as in large establishments (such as match factories and bidi-making firms) are often reported to be sexually exploited by their employers. This is also true for poor women who work as domestic helpers, hawkers, shopkeepers and also those employed in plantation, factory, construction, manufacturing and agricultural indus­ tries. Tribal women employed in these industries seem to be specially vulnerable to sexual exploitation. Victims of rape are not just sexually exploited, they are subject to sexual violence. Anecdotal reports about rape is quite common in Indian media but there does not seem to be any study yet of the pattern of indicating 540 Moni Nag the frequency, nature, and typology of people who are victims and perpetrators of this heinous crime. Male Homosexuals: One important reason for widespread social prejudice against homosexuality in India is almost total ignorance about homosexuals — their life­ style, habits, family situations, occupations, sexual development and behaviour and so on. Apart from any relevance to AIDS/STD, a better awareness about them among populace is expected to mitigate some wrong stereotypes associated with them and to make them a little more acceptable as fellow beings. The rapid spread of HIV infection and the likelihood that male homosexuals may be more vulnerable to it than heterosexual couples (see section on homosexuality) provide additional rationale for undertaking research on them, particularly the pattern of their sexual behaviour, on a priority basis. It is, however, not an easy task because although some homosexuals have come out openly with their sexual orientation, and news­ letters like Bombay Dost have provided a forum for public discourse about them, most of them are still not accessible and would be reluctant to talk about themselves with an unknown investigator. It is likely that these constraints would not be a serious handicap if investigators themselves are homosexuals and have access to their hideouts.

Sexual Network: This concept being used in sexual behaviour research countries, particularly in relations to AIDS/STD, has evolved out of the far more elaborate concept of social network in general social science research. It refers to the practice of having sexual relationship with multiple (two or more) partners not only in terms of the number of different sexual partners with whom individuals have relations over different periods of time but also with whom, and with how many people, the partners themselves have sexual relations. Knowledge of the extent of sexual networking and of how various types of persons are linked together through common sexual partners (for example, FSWs) is important for programme managers responsible for AIDS/STD prevention to help determine the potential spread of infection among various groups of population. A considerable proportion of men in India who have relations with FSWs also have relations with their wives and other women who are not FSWs. Persons involved in non-commercial sexual networks are usually un­ aware that their partner may link them to a network of sexual contacts involving a high risk of HIV infection. In India there has been no study so far of sexual networking but there is an urgent need of such studies centred around female and male sex workers and their clients. Surveys and quasi-anthropological studies done in Africa (Orobuloye et al., 1992) and in Thailand (Havanon et al., 1993) may provide some guidelines in this respect.

Women's Control over Sex in Marital Relations: India is still largely a patriarchal society in which women are generally dominated by men and have little or no decision making power in most household matters. But it should not be forgotten that social and economic changes affecting role and status of women have been occurring in India and perhaps not with a negligible pace in the middle class section of society. Not enough studies are being conducted to document the ongoing changes, particularly in the area of sexual decision making of married partners. Kapur's (1973) study of middle class working women showed some attitudinal changes regarding sex in a decade. Changes occurring in both attitude and control Sexual Behaviour and AIDS in India 541 over sexual relationship of women at least belonging to that class in the 1980s and 1990s are likely to be more significant. Findings obtained from the responses to the Debonair questionnaire are indicative of such changes. Women in general are perhaps not as powerless as often assumed in sexual relationship with their husbands compared to decision making in matters like household expenditure and children's education/health. But more empirical studies are needed to test such hypotheses.

Contents and Strategies of Sex Education among Adolescent Girls and Boys: Sex education suited to the needs of diverse groups of people should be an integral part of AIDS prevention programme but it is a very delicate, controversial and complex subject which raises many questions for which there are no easy answers. Who should be the targets for sex education? What should be its contents? What is the optimum strategy for imparting it? Contents and strategies of sex education for groups of people differing in age, sex, education and occupation should be tailored to the needs, interest and absorbing capacity of each group. But information necessary to do so among the diverse groups of people is very little. For example, the adolescent girls and boys in schools and out of schools will be quite different from FSWs and their frequent clients in this respect. In terms of prevention of AIDS/STD, both these groups deserve priority in sex education and, therefore, also in studying their specific needs, interest and absorbing capacity. Sexual terminolo­ gies easily comprehensible to each group need special exploration. Experimental research methods may be useful to identify the contents and strategies of sex education best suited for them.

Strategies for Increasing Use of Condoms among Vulnerable Groups: It can reasonably be assumed that prostitution cannot be obliterated in India and sexual relationship with multiple partners will continue on the same or increasing scale in the foreseeable future. But there are reports from countries with high prevalence of HIV infection that various combination of strategies have succeeded in increasing the use of condoms in vulnerable groups. In India also a few voluntary agencies in Bombay and Calcutta claim that they have succeeded in initiating significant changes in the use of condoms among small groups of FSWs. But so far no systematic and detailed studies have been done to document and analyse the strategies and processes which have made the successes possible. Such studies would provide useful lessons for similar programmes of other agencies — voluntary and government. Identification of appropriate strategies for increasing use of condoms among vulnerable groups is so important that it is worthwhile to undertake urgently a number of experimental research projects designed for the purpose.

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