Adolescent male reproductive health: awareness and behavior among peri-urban and rural boys in West Bengal, India.

Reproductive health is a serious concern not only for adults but also for male and female adolescents. The present study looks at the similarities and differences in reproductive health awareness and behavior among adolescent males living in peri-urban and rural areas of the State of West Bengal, India. Questionnaire data was collected from 111 school-age adolescent boys (55 peri-urban and 56 rural) between the ages of 15 and 18. Results show that the level of awareness about some aspects of reproductive health seems greater among peri-urban boys than their rural counterparts. However, in terms of reproductive health behaviors both groups appear similar.

Keywords: adolescent males, reproductive health, reproductive behaviors, West Bengal, India, peri-urban, rural

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The World Health Organization (WHO) refers to "adolescence" the period between 10-19 years. According to the Program for Appropriate Technology for Health (PATH) (2004), the world's adolescent population has exceeded the 1 billion mark, 85% of which live in developing countries (United Nations [UN], 1999; WHO, 1999); while some 700 million adolescents live in Asia (UN, 2000). In India, for example, adolescents make up about 22% of the population (IIPS & Macro, 2000; UN, 2001); while projections estimate that 15-19 year olds will make up 22.4% of the total national population by 2006 (Central Statistical Organisation [CSO], 1998).

Adolescence is a period of marked development regarding reproductive biology, and yet adolescents often lack knowledge of reproductive health issues. Adolescents' lack of knowledge concerning reproduction can be attributed to social and cultural barriers and their hesitancy to access family planning and reproductive health services compared to adults (Kilbourne-Brook, 1998). Consquently, adolescents may be at an increased risk of sexually transmitted diseases (STDs) including HIV, unintended pregnancy, and other consequences that can affect their futures as well as the future of their communities. Thus the reproductive and sexual health needs of adolescents are different from those of adults and are still poorly understood in most of the world. It is also true that the reproductive health needs and sexual behavior of adolescents vary with sex, marital status, class, region and cultural context (WHO, 2003; Pacahuri & Santhya, 2002).

Adolescent Males

At the meeting of International Council for Population Development (ICPD) held in Cairo in 1994 (UN, 1995a) and at the Fourth UN Conference on Women held in Beijing in 1995 (UN, 1995b), the importance of attending to the reproductive health of adolescent males along with that of females was recognized. Participants at both conferences concluded the reproductive health behaviors of adolescent males are not only directly related to the reproductive health of adolescent females, but also to their own health as future adults (WHO, 2000a). Across cultures, beginning in childhood, males and females are socialized by separate sets of practices, symbols, representations, norms, and social values that influence their expressions of masculinity and femininity, respectively (Bruce, Lloyd, & Leonard, 1995; Lamas, 1996; Ortner & Whitehead, 1996; Scott, 1996; Verma, 1997). In general, men are socialized to be dominant, aggressive, to cultivate toughness, and to take risks (O'Neil, Good, & Holmes, 1995). These qualities may have harmful consequences for both young men and their sexual partners, as these qualities may lead to young men to engage in high-risk sexual behaviors (Brown, Jejeebhoy, Shah, & Yount, 2001; Pleck, 1993). Moreover, males are socialized to be independent, self-reliant, to show little emotion, and to not seek assistance for health problems. Young men frequently ignore their reproductive health problems and rely mostly on self-treatments (WHO, 2000b). Adolescent males form one of the largest groups with unmet needs for reproductive health information and services. These unmet needs vary among different socioeconomic strata of the given society and also between rural and urban areas (Pachauri & Santhya, 2002; Porter & Koo, 2000).

Knowledge of Reproductive Health

Studies conducted on adolescent males in some Asian countries, including India, suggest that young men have many misconceptions about puberty and reproductive health. Among these misconceptions we find many have little knowledge about STDs, little or no communication with parents about sexual issues, and few informational resources about reproductive health. Research finds that many young men get information about sexuality and reproductive health from media and friends (Adjahoto, Hodonou, De souza, & Tete, 2000; Ali, Bhatti, & Ushijima, 2004; Hoy, 2001; Masilamani, 2003; Patil, Chaturvedi, & Malkar, 2002). However, some have found that adolescent males are willing to use more suitable sources to learn more about their reproductive health (Ali, Bhatti, & Ushijima; Kapamadzija, Bjelica, & Segedi, 2000; Zheng, 1997). A study in India, for example, showed that although the level of knowledge and awareness about puberty, menstruation, physical changes during puberty, knowledge about the male sex organs, reproduction, contraception, pregnancy, childbearing, reproductive tract infections (RTIs), and HIV were low among young adolescents (10-14 years of age), older adolescents (15-19 years of age) had a better knowledge of these issues (e.g., about 80% of older adolescents knew about STDs, including HIV) (Gupta, 1988). A baseline study conducted by the Centre for Population Studies and CINI (2003) found that over 90% of the young adults of the peri-urban areas around Kolkata (also known as Calcutta) were aware of HIV/AIDS, about 50% had knowledge about the transmission of the virus, and a large portion was aware of at least one of the reversible methods of birth control. The NACO National Behavioral Surveillance Survey reported that about 30% of the boys (15-19 years old) know how the HIV virus is transmitted, with slight variations between urban and rural boys (NACO & UNICEF, 2002).

Sexual Activity during Adolescence

In South East Asia, sexual activity during adolescence is associated with either early marriage or premarital sexual relations. Early marriage is a social norm of this region, which leads to early sexual activity and an increase of teenage pregnancy. In India, according to the Child Marriage Restraint Act of 1929 (amended in 1978), the statutory age limit for marriage is 21 for males and 18 for females. However, a large number of females marry before they reach the legal age, compared to a smaller number of the males. The national average for the age of marriage for women is 16.4 years, though this average varies from region to region (IIPS, 2000; Santhya & Jejeebhoy, 2003). Recently, however, statistics in the region have shown a trend toward later marriage for both males and females resulting in greater incidence of premarital sexual relations (Dixon-Mueller, 1993; Rai, 2001; Sharma, 2000; Singh & Samara, 1996; Uddin, 1999).

Globally, young people attain puberty at an earlier age and marry later. As a result, an individual remains sexually mature for a longer period of time prior to marriage (James-Trarore, Magnany, Murray, Senderowitz, Speizer, & Stewart, 2001). This is one of the major reasons for the increase of premarital sexual relations among adolescents (Boyd, 2000). Studies suggest the following percentages of adolescent males who have sex prior to marriage, by region: 24 to 75% in Asia, 44 to 66% in Latin America, 45 to 73% in sub-Saharan Africa, and 80% in some developed countries (Brown, Jejeebhoy, Shah, & Yount, 2001 ; Darroche, Singh, & Frost, 2001). Social and economic changes have eliminated many of the traditional restraints on premarital sexual activity and have exposed many adolescents, especially adolescent females, to the risks associated with unplanned pregnancy and abortion. In India, induced abortion became legal for married and unmarried women with the Medical Termination of Pregnancy (MTP) Act of 1971. Adolescents, especially unmarried females, who are unaware of the existence of abortion services and the right to avail the services, tend to seek the help of untrained and unqualified service providers, and thereby increase the risks to their reproductive health and well-being (Chhabara & Nuna, 1993; Dixon-Mueller, 1993; Ganatra & Hirve, 2002; Gupta, 2003; Jejeebhoy, 2000a). A number of Indian studies suggest that many adolescent males, especially in urban areas, engage in unprotected sexual intercourse, which makes them vulnerable to STDs (Abraham, 2001; Awasthi & Pande, 1998; Centre for Population Studies & CINI, 2003; Jejeebhoy, 2000b; Mawar et al., 1998; Mutatkar & Apte, 2001; Patil, Chaturvedi, & Malkar, 2002; Sriur, 2000; Verma, 1997). Reproductive tract infections (RTIs) and sexually transmitted diseases (STDs) are common in India. Some adolescent males, perhaps because of their sexual activity with sex workers, have higher (12-25%) reported cases of STDs than do adolescent females (Ramasubban, 1995). An Indian study reveals that some reproductive health morbidities for men are nearly identical to the rates found among women (Bang, Bang, Baitule, & Phirke, 1997). Another study conducted in rural West Bengal on men between 15-60 years of age suggests that the most common reproductive health complaint is urinary problems such as a burning sensation during urination and/or frequent difficulty at the time of urination (Dunn, Das, & Das, 2004).

Masturbation and pornography are two other common sexual behaviors used by adolescent males for sexual expression. Studies of Indian adolescent males find that around 20% masturbate (Gupta & Jain, 1998; Mehra, Savithri, & Cutinho, 2003; Patil, Chaturvedi, & Malkar, 2002; Sachdev, 1998; Sharma & Sharma, 1997), while some studies report that adolescent boys regard excessive masturbation and nocturnal emission as having ill effects (Awasthi, Nichter, & Pande, 2000; Patil, Chaturvedi, & Malkar, 2002).

Why Study Adolescent Males in Peri-urban and Rural Areas?

India is a country where an overwhelming majority of its people, including adolescents, lives in peri-urban and rural areas. In Indian society, especially in peri-urban and rural areas, reproductive and sexual health matters remain a hidden agenda and people feel uncomfortable discussing these issues openly. In order to develop better sexual and reproductive health, both government and non-government organizations (NGOs) have to be mindful of the needs of the large number of adolescents in peri-urban and rural areas.

It is commonly thought the people living in peri-urban areas (geographic areas circling or joining large metropolitan cities) have better socioeconomic conditions than their rural counterparts in terms of educational level, occupational types, exposure to the modernity of life, and communication systems. Consequently, awareness of health in general and reproductive health in particular should be better among peri-urban populations than rural populations.

The present study is an attempt to explore adolescent males' knowledge, awareness, and behavior regarding reproductive health in both peri-urban and rural settings.

Methods

Location of the Study

The study focused on adolescent boys attending school and residing in peri-urban and rural areas in the State of West Bengal, India. This state has the country's second highest literacy rate and has large-scale socioeconomic diversity. The State of West Bengal is situated in eastern India with the city of Kolkata as its capital. Kolkata is situated on the eastern bank of the river Ganga. Across the river Ganga, on its western bank is with its peri-urban environment, which is quite different from the city of Kolkata. For our study's purpose then, Howrah is representative of peri-urban locality (outskirts of a larger urban area). Initially, the researchers approached two schools from this area. However, one of the school's authorities later declined to participate because the students' annual examination was about to commence. Thus, only one school located in the peri-urban area participated in the study.

Likewise, two schools were initially contacted to represent the study's rural (R) portion. Both schools are situated in Demur, a place situated in the district of Howrah. However, the authorities from one of the schools also declined to participate, as they believed the research topic was too sensitive for their student body. Consequently, another school from the Burdwan district (adjacent to the district of Howrah) was selected. Both the schools selected to represent rural school are located approximately 60 kms. outside Kolkata. The criteria for selecting these schools (both peri-urban and rural) was based on a set of shared features, same language for instruction (i.e., Bengali), their similar tuition fees, male-only student body, and their similar curriculum (i.e., up to the 12th standard.

Subjects

The participants were 111 adolescent males between 15-18 years studying in three schools (55 peri-urban and 56 rural). The median age for both groups was 16.0 years.

Method of Data Collection

Before collecting the data, the nature and importance of the study were explained to the respective school authorities and the students. Data on social demography and reproductive health awareness, knowledge, and behavior were collected with the help of a well-tested structured questionnaire/schedule. After agreeing to participate, the first author (BMD) interviewed each of the subjects independently in a separate location inside the school premises. Prior to the actual interview the researcher discussed topics like sports, literature, and movies to put the participants at ease and build rapport. Each interview lasted approximately 40-50 minutes. Data was collected during the school hours, i.e., between 10 a.m. and 5 p.m.

Classification of Data

Participants' age and educational levels as well as their parents' occupations and household income were collected. Data on knowledge and awareness of reproductive health included responses to questions regarding: HIV/AIDS and its modes of transmission, STDs, condoms, sexual intercourse and safe sex practices; the development of secondary sexual characteristics at the time of puberty in males and females, the male reproductive system and its function, perceptions about the cause of pregnancy and the process of conception; acquaintance with the types of contraceptives, abortion in general and the legality of induced abortion in India (both for married and unmarried women), statutory age of marriage for males and females in India, views about inclusion of sex education in the school curriculum, and sources from which information on reproductive health has been gathered. Data on reproductive behavior included ways of fulfilling sexual urges, experience of ejaculation and masturbation, frequency of masturbation in the last week (preceding the date of the interview), types of feelings after masturbation, perceptions about the effect of masturbation on health, experience of nocturnal emissions, and sexual intercourse.

Duration of the Study

The study's data collection took place between February and August 2005.

Results

Socioeconomic Conditions

The parents' socioeconomic levels were measured in terms of their educational level and occupational types. A majority of both the fathers (76.36%) and mothers (58.18%) in the peri-urban areas had obtained an educational level above the secondary level (10th standard) compared to only 57.14% of the fathers and 37.5% of the mothers of the rural areas.

Most of the peri-urban boys' fathers are engaged in business (47.27%), followed by service industries (45.45%). A majority of the rural boys' fathers are engaged in business (32.14%), followed by farming (26.78%), and service industries (25%). Most of the mothers of the peri-urban and rural boys are full-time housewives.

The monthly household income of 47.27% of the peri-urban subjects was Rs. 5000 (USD $100) and above, compared to 23.21% of their rural counterparts at that income level.

Reproductive Health

Awareness of sexually transmitted diseases. With the exception of five of the rural adolescent males, most boys from both groups understood the different modes of transmission of HIV/AIDS, such as sexual intercourse (PU 100% and R 92.15%), sharing of infected needles (PU 85.45% and R 60.78%), and infected blood transfusion (PU 78.18% and R 64.7%). However, the peri-urban boys appeared slightly more knowledgeable about the different modes of HIV/AIDS transmission. A small portion from both the groups (PU 16.36% and R 11.76%) believed that HIV/AIDS could be transmitted through water, mosquito bites, superficial human body contacts, and human excreta. None of the boys from these two latter groups appeared to have any knowledge about other STDs (e.g., gonorrhea and syphilis).

Discussing sex-related issues with friends was common among both groups of boys. Some of the topics and the percentages reporting discussing such topics were: HIV/AIDS (PU 85.45%, R 57.14%), sexual relations (PU 94.54% and R 67.85%), use of condoms (PU 90.9% and R 69.64%), sexual intercourse (PU 89.09% and R 62.5%), and safe sex practices (PU 12.72% and R 3.57%).

Knowledge of the development of secondary sexual characteristics at the time of adolescence. A large portion of the boys reported the appearance of pubic hair (PU 100.0% and R 96.42%), axillary hair (PU 98.18% and R 83.92%), facial hair (PU 96.36% and R 71.42%), body hair (PU 85.45% and R 46.42%), change of voice (PU 94.54% and R 98.21%) and change in the size of the penis (PU 98.18% and R 92.85%) as the major secondary sexual characteristics that develop among males at the time of adolescence. The adolescent males of both groups reported development of breasts (PU 100% and R 87.45%), axillary and pubic hairs (PU 96.36% and R 48.21%) and attainment of menarche (PU 67.27% and R 30.35%) as the major secondary sexual characteristics that develop in females at the time of adolescence. However, it appears that in general, the peri-urban boys are more aware about the development of secondary sexual characteristics than their rural counterparts.

Knowledge of reproductive biology. To test the boys' knowledge of reproduction, they were asked seven questions and their answers were recorded (Table 1 contains the seven questions, the "correct" answers, and the numbers and percentages of "correct" and "incorrect" answers given by both groups.

Looking at Table 1, we see that most of the boys from both locations didn't give the "correct" answer for Item 1 as most didn't know the answer or reported only the "penis" as the male sex organ. It seems that the rural boys are more unaware than their peri-urban counterparts about the male sex organ, but the difference is not statistically significant. On the other hand, a majority of the adolescents of both groups were able to state the functions of penis (Item 2) correctly. The peri-urban boys seemed to be more aware than their rural counterparts, but the difference was not statistically significant. For item 3, less than 50% of the peri-urban boys and less than 20% of the rural boys had the correct idea about the place of formation of semen, and in this case the difference was statistically significant. The odds ratio suggests that the peri-urban boys are 4.04 times more likely to have the knowledge about the place of formation of semen than the rural boys. More than 50% of the peri-urban boys, compared to more than 25% of their rural counterparts, knew that sperm is one of the components of semen (item 4); the difference is statistically significant. The odds ratio suggests that the adolescent males of peri-urban areas are 1.41 times more likely to have the knowledge that sperm is one of the components of semen than the rural males. It appeared from item 5 that more than 65% of the peri-urban boys had the correct knowledge about the function of sperm, compared to 28.57% of the adolescents of the rural area, and again, the difference is statistically significant. The odds ratio suggests that the adolescent males of the peri-urban area are 5.13 times more likely to have correct knowledge about the function of sperm than the rural males. For item 6, it was found that all the adolescent males of the peri-urban area and an overwhelming majority of the rural boys had the "correct idea" about the cause of pregnancy (item 6) and the difference is statistically significant. However, few of the adolescents in either group possessed the "correct idea" about the process of conception (Item 7).

Knowledge about family planning methods. The adolescent males of both the groups were asked to name the common family planning methods generally adopted by the people in this region. In general, the adolescents of both the groups (barring 4 of the rural boys) were aware of the practice of different reversible and irreversible methods of family planning such as the use of condoms (PU 94.54%, R 78.84%), administration of oral pills (PU 85.45% and R 55.76%), practice of withdrawal (PU 41.81% and R 41.07%), vasectomy (PU 16.36% and R 3.84%) and tubectomy (PU 20.0% and R 26.92%). A majority of both the groups were found to be aware of at least two of these family planning methods (PU 89.09% and R 65.38%); a smaller portion were aware of at least one method (PU 10.9% and R 34.61%), and the difference is statistically significant ([chi square] = 8.63, df = 1 , p < 0.01).

Knowledge about the legal provision of abortion and age of marriage. The following are the right answers to items 2, 3 and 4 (a & b) mentioned in table 2. Subjects who were able to answer any of the items correctly were considered to have an awareness for that item and those who could not answer these items correctly or totally unaware of have been considered to have no awareness.

Items 2 and 3: Subjects who reported that induced abortion (1) in general and (2) in cases of unmarried females are legal in this country were considered to have the right knowledge, independent for each of the items.

Items 4(a) and (b): Subjects who answered that the statutory age at marriage in India for (a) males is 21 years and that for (b) females is 18 years were considered to have the right knowledge, independent for each of the items.

It appears from table 2 that about 50% of the adolescent males of the peri-urban area had knowledge of abortion (item 1) compared to around 10% of the rural males, and the difference is statistically significant. The odds ratio suggests that the peri-urban boys are 7.26 times aware about abortion than their rural counterparts. Though abortion has been legalized in this country since 1971, less than 20% of the peri-urban boys and none from the rural area are aware of its legality in the case of married women (item 2), and the difference is statistically significant. The knowledge about the legality of abortion in the case of unmarried women (item 3) seems to be negligible in the case of peri-urban boys and nonexistent in the rural area. From this table it appears that half of the adolescent males of peri-urban areas are aware of the statutory age of marriage for males (item 4a) against one third of their rural counterparts, and the difference is statistically significant. The odds ratio also suggests that the peri-urban boys are 2.78 times more aware about the statutory age of marriage for males than their rural counterparts. However, an overwhelming majority of the individuals of both the groups knew the statutory age of marriage for females (item 4b) in this country.

Sources of information about reproductive health matters. An overwhelming majority of the adolescent males of both the groups have at least two sources (PU 70.91% and R 87.5%) from which they get information about the reproductive health matters, followed by a smaller percentage who reported having at least three sources (PU 29.09% and R 25.5%). Friends were the major source from which the adolescents of both the groups acquired this information (PU 100% and R 91.07%) followed by books (PU 72.72% and R 69.64%) and media (PU 25.45% and R 17.85%).

Adolescent males of both groups (PU 96.36% and R 92.85%) expressed their view that a course related to reproductive health should be included in the school curriculum, and 30% of them preferred inclusion of this course from the 9th standard.

Reproductive Behavior

Ways to Fulfill the Sexual Urge

All the adolescent males of both the groups (except 4 of the rural area) reported having sexual urges, and the majority of them fulfill this through masturbation (PU 87.27% and R 78.57%) and/or looking at pornographic materials (PU 72.72% and R 51.78%). The median age of masturbation and ejaculation (both for the first time) for the individuals of both groups was found to be 14.0 years.

Table 3 shows that a majority of the adolescent males of both groups have experienced masturbation (PU 87.27% and R 78.57%) and most of them have masturbated three times or more in the one week period preceding the date of survey. Mostly, the stimulations for masturbation for these individuals are pornographic materials (PU 50% and R 45.45%) and fantasizing some sexual incident or some romantic ideas (PU 68.75% and R 72.72%). In general, the individuals of both the groups expressed that after masturbation they had a feeling of satisfaction (PU 91.66% and R 56.81%) and/or a feeling that it would harm the body and soul (PU 62.5% and R 84.09%). An overwhelming majority of them (PU 62.5% and R 81.81%) felt worried when they masturbated excessively, and the difference is statistically significant. The odds ratio suggests that the peri-urban boys are less worried about excessive masturbation than the rural ones by 0.37 times. Most of the individuals of both groups believe that the act of excessive masturbation makes a person weak. Nocturnal emission had been experienced by less than half of the boys of both the groups (PU 47.27% and R 39.28%). All the boys of both the groups, irrespective of their experience of nocturnal emission, perceived the event as a sexual problem. A few of the adolescent males (PU 20% and R 7.14%) had experienced unprotected sexual intercourse. Among the rural boys who had experienced sexual intercourse, all had experienced vaginal intercourse with girls of their peer group. Among the peri-urban boys who had experienced sexual intercourse, a majority of them experienced vaginal (10) and a few anal (1) with the same sex. The peri-urban males reported that their sexual partners were girls and boys (in case of anal) of their peer group (8), or sisters-in-law (2).

Discussion

The present study was conducted on school-age adolescent males from two different socioeconomic settings: peri-urban and rural areas of the State of West Bengal, India. The present study sought to determine the knowledge, attitudes, and behavior among these adolescents regarding their reproductive health as well as determining similarities and differences between them.

The findings reveal that the adolescent males of both the groups show a similar trend on issues such as: HIV/AIDS and its modes of transmission; the male sex organs and function of the penis; the development of secondary sexual characteristics in males at the time of puberty; the process by which a woman can conceive; the legality of abortion for unmarried women in India; the statutory age of marriage for females in India; the sources from which information on reproductive health awareness have been acquired; relations with whom sex related issues are discussed; and support for the inclusion of sex education in school curriculum. On the other hand, the peri-urban boys seem to be more aware than their rural counterparts regarding issues such as: the tendency to discuss different types of sex-related matters; perceptions about the development of some of the secondary sexual characteristics in females at the time of puberty; knowledge about the place of production of semen; composition of semen and function of sperm; correct idea about the cause of pregnancy; knowledge about the various types of contraceptive devices; knowledge about abortion and its legality in India; and statutory age at marriage for males in India. In reproductive behavior, a similar trend was observed between the adolescent males of both the groups on matters related to satisfying sexual urges by the act of masturbation, the median age of masturbation and ejaculation, frequency of masturbation (during previous one week period) and stimulation for masturbation. However, the peri-urban and rural boys differ in their attitudes regarding the fulfillment of sexual urges by looking at pornographic materials, their perceptions about the ill effect of masturbation on health, and the experience of sexual intercourse.

Thus, it appears from the above discussion that both similarities and differences exist in the reproductive health awareness between the peri-urban and rural boys, but in reproductive behavior, both the groups are largely similar, barring a few.

In general, the present findings reflect that adolescent males have a poor level of knowledge regarding reproductive health and limited communication on these issues with family members, which corroborates the findings from some earlier studies conducted in India and some other Asian countries (Adjahoto, Hodonou, De souza, & Tete, 2000; Ali, Bhatti & Ushijima, 2004; Hoy, 2001; Masilamani, 2003; Patil, Chaturvedi, & Malkar, 2002;). Since the topic of reproductive and sexual health is considered taboo among the adolescents in most societies in the developing world, and as there is hardly any proper source from where they can acquire appropriate knowledge on these issues, most of the young people remain ignorant. However, a high level of awareness about HIV/AIDS and its mode of transmission, as found in both the present study and in some earlier studies (Centre for Population Studies & CINI, 2003; Gupta, 1988) indicates the success of the effort taken by the governmental and nongovernmental organizations in India to make the general population aware of this dreadful disease. A report prepared on the young men of peri-urban areas of Kolkata (West Bengal) shows that the knowledge about the reversible methods of family planning (especially use of condoms and oral contraceptives) is very high (Centre for Population Studies & CINI, 2003); the present research on the adolescent boys of this region gives a similar picture. However, both these findings from West Bengal contradict another study conducted by the IIPS (1995), which shows that an overwhelming majority of the adolescents in India are more aware of sterilization, compared to any other methods of family planning.

The development of better reproductive health awareness among adolescents will remain incomplete if information about basic reproductive biology is not imparted to them. Many adolescents in south Asia are poorly or incorrectly informed about sexual issues, reproductive biology and health. A low level of school attendance, lack of sex education and the presence of attitudes that prohibit discussion of sexual issues all confound to exacerbate ignorance in these matters (Bott & Jejeebhoy 2003; McCauley & Salter 1995). A study conducted by Gupta (1988), along with the present study, demonstrates a lack of knowledge among adolescent regarding reproductive biology.

Premarital sexual activities during the adolescent period increase the risk of unwanted pregnancy among teenage girls. Generally in Indian society, pregnancy as a result of premarital sex is a matter of shame, and these pregnancies mostly end up with induced abortions. As many are unaware of the fact that abortion is legal in this country, some 80% of the abortions are performed illegally in private institutions and by untrained persons in unhygienic conditions, putting a woman's life at risk (Chhabra & Nuna, 1993; Ganatra & Hirve, 2002). In the present study it was found that a large section of adolescent males who are likely to be the sexual partners of their female counterparts are unaware about the legality of abortion.

Enhancing access to reproductive health information and services targeted to adolescents is a big challenge. The present study, as well as other studies conducted in other Asian countries, reveal that adolescents acquire reproductive health related information predominantly from their peer groups and/or independently by going through books (Adjahoto, Hodonou, De souza, & Tete, 2000; Ali, Bhatti & Ushijima, 2004; Hoy, 2001). One of the suggested main channels to reach adolescents is through the schools. As summarized in a study from the U.S.A, adolescent males who had dropped out of school received significantly less reproductive health education than those who stayed in school (Lindberg, Ku, & Sonenstein, 2000). In this part of the developing world, inclusion of reproductive health information in the school curriculum still remains a delicate issue, but adolescents in the present study have expressed their keen desire in its favor.

In India, though pornography is legally banned, these materials are widely available in various forms such as, films, magazines, writings, photographs and internet sites. A large section of adolescents in India, including the ones of the present study (especially the peri-urban boys), have access to these pornographic materials and use these materials to pacify their sexual urges (Sachdev, 1998; Sharma & Sharma, 1996). Masturbation is another common sexual behavior of the adolescent males. In India, data on masturbation is limited and it appears that adolescents of the present study group masturbate 4 times more often than boys of earlier studies (Gupta & Jain, 1998; Mehra, Savithri, & Cutinho, 2003; Patil, Chaturvedi & Malkar, 2002; Sachdev, 1998; Sharma & Sharma, 1997). There is a common notion among the people of this country that excessive masturbation may harm body and soul and make a person weak. In addition, the occurrence of nocturnal emission/wet dreams (swapna dosh) is perceived as a sexual problem. An overwhelming majority of the adolescents in the present study, as well as some other studies on Indian adolescents, corroborate the same finding (Awasthi, Nichter, & Pande, 2000; Patil, Chaturvedi, & Malkar, 2002). In India, there are a large number of private clinics that advertise in public places in the form of bills/posters to offer non-western medical treatment for nocturnal emission/wet dreams and for other reproductive health problems (gupta rog, which means secret disease). However, detailed data about these clinics, the nature of treatments they offer, the age group of the clients who visit these clinics, and the type of problems mostly attended to, are not available.

From studies conducted in the 1990s it appears that about 20-35% of the young men in India have experienced sex before marriage, with a very little difference between rural and urban males (Pelto, 2000). Premarital sexual experiences may be both penetrative (sexual intercourse of any type) as well as non-penetrative (e.g., kissing, hugging, touching sexual organs) in nature. In general the non-penetrative types of sexual activities are practiced more than the penetrative type among unmarried adolescents (Abraham, 2001; Abraham & Kumar, 1999; Centre for Population Studies & CINI, 2003). Moreover, penetrative sexual intercourse is generally perceived as profane in Indian society. In the present study only penetrative sexual experiences or intercourse were considered because these activities have direct consequences to STDs and RTI. In India, it has been observed that information regarding adolescent males and premarital sexual intercourse varies with the technique applied in collecting the data. Data collected by self-administered questionnaire gives a higher rate of report compared to data collected by face-to-face interview (Jejeebhoy, 2000b). The present study on adolescent males was conducted with the latter technique and has been compared with the findings from other studies conducted by the same technique. The result shows that in the present study a higher number of peri-urban adolescents (20%) have experienced sexual intercourse compared to another study conducted on the young people of peri-urban area of Kolkata (12.9%), on the urban adolescents of Gujarat (9%) and on the urban slums of Mumbai (9%). Moreover, the present findings show a reverse trend in the difference between rural and urban subjects regarding the frequency of premarital sexual intercourse when compared with the study from Gujarat (Sharma & Sharma, 1997). It is interesting to note that none of the adolescents of the present study used condoms at the time of sexual intercourse and did report having sex with commercial sex workers as similarly reported by other research from India (Centre for Population Studies & CINI, 2003; Sharma and Sharma, 1997; Patil, Chaturvedi & Malkar, 2002).

Thus, it appears that except for a few traits, the trend of reproductive health matters of adolescent males in West Bengal largely corroborates the pan-Indian situation.

To the best of the authors' knowledge, the present research is a maiden attempt to explore the adolescent male reproductive health situation in the eastern part of India. As the study is based on a small sample size, with the subjects selected from only three schools, the authors do not claim the findings to be conclusive. However, the trend that emerges from this exploration gives a lead for conducting future research on this topic in this region and also enhances the existing database from India in particular and Asia in general. A more detailed investigation with a larger sample size including the adolescent males of the urban sector, and with an understanding of the process of socialization of these adolescent males, will reveal a better picture of the reproductive health situation.

After a prolonged debate the Government of West Bengal (the state where the present study has been conducted) recently introduced a program that will address the reproductive health issues of adolescents who are at school in the 6th, 7th, and 8th standard. Under this program, secondary school teachers will have to go for training which will provide them with information on how to provide reproductive health information to the students in an effective way. The entire program will be treated as a compulsory extra curricular activity. Further, the Department of Secondary Education of the State of West Bengal has brought out a handbook named Jeebon Shaily (both in English and Bengali languages), which provides information on reproductive health. The initiative taken by the government is appreciable though it is at too nascent a stage to warrant any comment. However, it seems that the school-goers will benefit from this program. But what about the large section of boys who is not at school?

The authors of the present study suggest that along with the growing awareness of reproductive health, equal effort should be given to develop knowledge of reproductive biology, to increase the general awareness of certain legal provisions related to reproductive health, and to remove certain misconceptions about reproductive behavior among the males of this age group. But how this can be done is beyond the purview of the present research.

The authors are indebted to the school authorities and the students for their cooperation in data collection. We are grateful to Dr. Susmita Mukhopadhyay and Mr. Shailendra Mishra of BAU, Indian Statistical Institute. Kolkata for providing academic help in connection with this work. Partial financial support received from DSA Phase III (UGC) is thankfully acknowledged.

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Bhubon Mohan Das, Department of Anthropology, University of Calcutta; Subha Ray, Department of Anthropology, University of Calcutta.

Correspondence concerning this article should be addressed to Subha Ray, Department of Anthropology, University of Calcutta 35, Ballygunj Circular Road, Kolkata 700 019, India. Electronic mail: [e-mail]

Table 1
Knowledge about Reproductive Health Matters

                                   Peri-urban    Rural

1. What is (are) the male sex organ(s)? (Correct answer: Penis and
testes.)

Answered correctly                     7           4
                                    (12.72)     (7.14)
Answered incorrectly or no answer      48         52
                                    (87.27)     (92.85)

2. What is (are) the function(s) of the penis? (Correct answer:
Passing of urine and ejection of semen.)

Answered correctly                     44         39
                                     (80.0)     (69.64)
Answered incorrectly or no answer      11         17
                                     (20.0)     (30.35)

3. Where is semen formed? (Correct answer: Testis.)

Answered correctly                     24          9
                                    (43.63)     (16.07)
Answered incorrectly or no answer      31         47
                                    (56.36)     (83.92)

4. Where is major composition of semen? (Correct answer: Sperm.)

Answered correctly                     33         15
                                     (60.0)     (26.78)
Answered incorrectly or no answer      22         41
                                     (40.0)     (73.21)

5. What is the function of sperm? (Correct answer: Fertilize a woman's
egg or ova.)

Answered correctly                     37         16
                                    (67.27)     (28.57)
Answered incorrectly or no answer      18         40
                                    (32.72)     (71.42)

6. What is a major way to cause pregnancy? (Correct answer:
Sexual intercourse.)

Answered correctly                     55         49
                                    (100.0)     (87.5)
Answered incorrectly or no answer      --          7
                                     (12.5)

7. Does intercourse always lead to conception? (Correct answer:
Sexual intercourse does not always lead to conception.)

Answered correctly                     12         16
                                    (21.81)     (28.57)
Answered incorrectly or no answer      43         40
                                    (78.18)     (71.42)

                                    [Chi.sup.2]    Odds Ratio(CI 95%)

1. What is (are) the male sex organ(s)? (Correct answer: Penis and
testes.)

Answered correctly                      0.97              1.89
                                                      (0.52-6.81)
Answered incorrectly or no answer

2. What is (are) the function(s) of the penis? (Correct answer:
Passing of urine and ejection of semen.)

Answered correctly                      1.58              1.74
                                                      (0.72-4.14)
Answered incorrectly or no answer

3. Where is semen formed? (Correct answer: Testis.)

Answered correctly                    10.09 **           4.04 *
                                                      (1.64-9.77)
Answered incorrectly or no answer

4. Where is major composition of semen? (Correct answer: Sperm.)

Answered correctly                    12.47 **           1.41 *
                                                      (1.85-9.02)
Answered incorrectly or no answer

5. What is the function of sperm? (Correct answer: Fertilize a woman's
egg or ova.)

Answered correctly                     5.13 *           16.66 **
                                                      (2.29-11.45)
Answered incorrectly or no answer

6. What is a major way to cause pregnancy? (Correct answer:
Sexual intercourse.)

Answered correctly                     5.37 *              --

Answered incorrectly or no answer

7. Does intercourse always lead to conception? (Correct answer:
Sexual intercourse does not always lead to conception.)

Answered correctly                      0.67              0.69
                                                      (0.29-1.63)
Answered incorrectly or no answer

*Significant p < 0.05, ** Significant p <0.01, *** Significant p < 0.001

Figures in the parenthesis indicates percentages.

Table 2
Knowledge about Some Legal Provision Related to Abortion and Age of
Marriage

          Peri-urban    Rural    [Chi.sup.2]    Odds Ratio

1. Knowledge about abortion                      (CI 95%)

Present       28          7       18.96 ***        7.26
            (50.9)     (12.5)                   (1.04-2.92)
Absent        27         49
           (49.09)     (87.5)

2. Knowledge that induced abortion is legal in case of married women

Present       10          0        9.08 **          --
           (18.18)       --
Absent        45         56
           (81.81)     (100.0)

3. Knowledge that induced abortion is legal in case of unmarried women

Present       2           0          0.52           --
            (3.63)       --
Absent        53         56
           (96.36)     (100.0)

4 (a). Knowledge about the statutory age at marriage for males

Present       29         16        6.72 **        2.78 *
           (52.72)     (28.57)                  (1.27-6.04)
Absent        26         40
           (47.27)     (71.42)

4 (b). Knowledge about the statutory age at marriage for females

Present       44         37          2.73          2.05
            (80.0)     (66.07)                  (0.86-4.81)
Absent        11         19
            (20.0)     (33.92)

* Significant p < 0.05, ** Significant p < 0.01,
*** Significant p < 0.001

Figures in the parenthesis indicates percentages

Table 3 Sexual Behavior

                   Peri-urban    Rural    [Chi.sup.2]    Odds Ratio
                                                           (CI 95%)

1. Experience of masturbation

Yes                    48         44          1.48           1.87
                    (87.27)     (78.57)                  (0.67-5.10)
No                     7          12
                    (12.72)     (21.42)

2. Frequency of masturbation in the last one week period

Never (#)              14         19          0.95
                    (25.45)     (33.92)
Once only              11          9
                    (20.00)     (16.07)
Twice only             11         11
                     (20.0)     (19.64)
Thrice and above       19         17
                     (34.5)     (30.36)

3. Perception about the effect of masturbation on health

(a) Worried about excessive masturbation

Yes                    30         36         4.2 *          0.37*
                     (62.5)     (81.81)                  (0.14-0.97)
No                     18          8
                     (37.5)     (18.18)

(b) Belief that masturbation makes a person weak

Yes                    41         48          2.18           0.48
                    (74.54)     (85.71)                  (0.18-1.28)
No                     14          8
                    (25.45)     (14.28)

4. Experience of nocturnal emission

Yes                    26         22          0.72           1.38
                    (47.27)     (39.28)                  (0.65-2.91)
No                     29         34
                    (52.72)     (60.71)

5. Ever experienced sexual intercourse

Yes                    11          4          2.9            3.25
                     (20.0)     (7.14)                   (0.98-10.59)
No                     44         52
                     (80.0)     (92.85)

* Significant p < 0.05

(#) includes PU 7 and R 12 number of boys who have not yet
experienced masturbation

Figures in the parenthesis indicates percentages