Sexual attitudes and behaviors of school students (grades 6-12) in India.

As of January 1994, the World Health Organization (WHO) had reports from 206 nations of approximately 851,000 cases of ADDS and an estimated 8-14 million cases of HIV infection. In most countries the number of people reported with AIDS doubles every 6-12 months (Cox, 1994). By the end of 1995, WHO estimated there would be more than 6 million AIDS cases and approximately 20 million people infected with the virus. By 2000 it is projected that 10 million children and 30 million adults will be infected with HIV Michael Merson, director of the Global Program on AIDS, added that the global balance of HIV infection is rapidly tipping toward the developing countries. Of the world's total cases, it is estimated that, by 1985, 50% were in the developing countries, by 2000, 75430% will be in the developing countries; and by 2010, as many as 90% of cases will be in developing countries (Stine, 1995). WHO predicts that by 2000 the Asian continent will lead the world in the number of AIDS cases.

The third world countries where AIDS cases are going to increase are the ones that cannot match the technical, physical, and support resources of the developed nations to deal with AIDS. The social impact of HIV/AIDS in the developing countries will be felt differently; the areas of impact are the economy, demographics, labor productivity, agricultural production and development, pressures on the health care sector, families and households, children, women, HIV/AIDS discrimination, and the impact of AIDS on the individual (Danziger, 1994). Education and behavioral risk reduction will be the only route of survival in third world countries for many years to come. This does not bode well for the developing nations and especially India, the most densely populated country in Asia and the second most populous country in the world.

India's population of 900 million people is growing at an annual rate of 2.1%. The goal of the Family Planning Association of India WAD, a nongovernmental organization that formulates national plans for family planning and reproductive health, is to reduce the population growth rate to 1.25% annually by 2000 (FPAI, 1992). If AIDS and HIV transmission continue to spread at present rates, the ramifications will be global, which very few people seem to realize.

The first cam of AIDS in India was reported in 1986; as of 1993 there were 1,032 documented cases of AIDS [National AIDS Control Organization (NACO), 19931. However, WHO estimates that 1.6 million people already are infected with HIV (Bollinger, Tripathy, & Quinn, 1995). It is estimated that about 5 million people will be infected with HIV, and by 2000 the number of AIDS cases will exceed 1 million in India (NACO, 1993). The primary mode of HIV transmission in India is heterosexual contact, except in the northeastern region, where in travenous drug use is the primary cause of transmission. Ninety percent of the cases reported to date were among those below the age of 50, and more than two thuds of these persons were between 20 and 40 years of age. Given HIV's incubation period of 10 years, it seems likely that these people were infected as teenagers. Hence, to prevent infection from spreading, younger age groups need to be targeted for educational programs.

The Indian government, through the Ministry of Health and Family Welfare, in collaboration with WHO, established NACO, which formulated an action plan to deal with the burgeoning AIDS epidemic. NACO has been operational since 1987 but first developed strategic plans to combat AIDS in 1992. One of NACO's strategies to control the spread of the disease is to mandate sexuality education programs nationally. To implement the proposed plans and strategies, there is a need for baseline data against which progress can be measured. To bridge this gap in information regarding sexual behaviors and practices, NACO has funded 65 risk-behavior studies, mainly through local initiatives, Non Government Organizations (NGO), and social institutions (personal communication with Dr. P. R. Dasgupta, 1994).

In the United States, little is known about the sexual attitudes and behaviors of boys and girls aged 10-17 years [Sexuality Information Education Council of Sexuality (SIECUS), 1994]. AIDS continues to be the number one killer of young people ages 25-44 years [Center for Disease Control (CDC), 1995]. Ndeki, Klepp, Seha, and Leshabari (1994) surveyed 2,026 6to and 7to grade students aged 10-17 years in Northern Tanzania and reported low levels of knowledge, particularly with respect to risk associated with casual contact. Bertrand, Makani, Hassig, and Niwembo (1991) surveyed 3,140 men aged 20-49 years and 3,485 women aged 15-49 years in Zaire. They reported universal awareness of AIDS, although some misconceptions did exist regarding the mode of transmission. There is a similar lack of data on the sexual behavior of the Indian population, especially adolescents. The paucity of information regarding the spread and progression of HIV, level of knowledge, attitudes, and behaviors of the Indian people is mentioned by several researchers working with the Indian population (Bollinger et al., 1995; Porter, 1993; Tikoo, Bollman, & Bergen. 1995 Most research, to date, has been clinical and has been concentrated on at-risk populations--commercial sex workers, sexually transmitted disease (STD) clinic patients, intravenous drug users, and commercial blood donors (Bollinger et al.. 1995: Jacob, Jayakumari, John, & John, 1989; Jain, John, & Keusch, 1994.) Very few researchers have explored sexual behaviors, attitudes, and knowledge of Indian adolescents. This information is crucial to policy planners, teachers, and other professionals working in education, as India is just starting to plan a comprehensive sexuality education program, which will be mandated in schools nationally.

How do knowledge, attitudes, and behaviors interact and influence a person? Because each individual and each situation is unique, behavior is often difficult to predict. Population and cultural diversity in India makes it difficult for any one program to be universally applicable, unlike the situation in countries with small, homogeneous populations.

AIDS and Sexuality Knowledge in India

The need for sexuality education in schools was well documented at the five-day Asian Sexology Conference held in December 1994 in New Delhi, with emphasis on reproductive health education issues throughout India and Asia. A draft proposal for a National Sexual Health Program was submitted to the Ministry of Health. The results of the few existing studies on AIDS knowledge and the current spread of HIV highlight the need for understanding behavior, attitudes, and knowledge of Indians regarding human sexuality and AIDS before comprehensive national planning can start.

A survey (Sex Education Counseling Research Training and Therapy Department, 1988) of 3,850 unmarried urban young men and women (15- to 29-year-olds) revealed no significant differences across regions in the attitudes of the young people regarding marriage and Sex. Liberal attitudes toward Sexual behavior were found among both young men and women who were looking for equality in marriage. Most desired to stay in a "joint or extended family." and "arranged marriages (parents help in the selection of the significant others)," with some modifications, were still preferred by 60% of the sample. However, they also expressed the need to break away from tradition and marry out of their caste or religion. These findings indicate that there may be much ambiguity between the attitudes they hold and the behavior that they actually select.

Two thirds (1,365) of the sample surveyed by Pathak (1994) indicated that they would settle for an arranged marriage while having casual premarital affairs on the side. AIDS and other STDs do not seem to be a concern for this generation. As a result of being exposed to sexual messages from television and cinema, adolescents in India are increasingly experimenting with sexual behaviors.

Porter (1993) surveyed 153 English-speaking adults in Calcutta regarding their knowledge and attitudes about AIDS. The group was select in the sense that 60% had attended college, and 87% of the men and 99% of the women had heard about AIDS. Misconceptions existed, and both men and women lacked specific knowledge about AIDS. Mere awareness of the disease is not a precursor to an understanding about modes of transmission and symptoms of the disease. Even though 93% of the sample was aware of AIDS, they were ignorant about its symptoms, and prejudices against people with AIDS were omnipresent

Jain et al. (1994) reported that 58% of Indian patients attending a general outpatient clinic, 77% of patients attending an STD clinic, and 96% of commercial sex workers lacked knowledge about HIV/AIDS. They also reported that misinformation was widespread and was not limited to uneducated individuals. Although educated individuals had more accurate knowledge, their attitude was that AIDS was a foreign problem and would not affect Indians.

Chowdhury and Gill (1993) reported that of their sample (716 Grade 12 students), 18.5% agreed that only prostitutes get AIDS, 11.8% agreed that only homosexuals get AIDS, 35.6% agreed that anybody can get AIDS, 67% reported that they were not the type of person to contract AIDS, 36% of the students believed that they could do little to protect themselves against AIDS, and 17% of the boys and 917, of the girls would actually risk AIDS rather than miss the chance of having sex with an attractive stranger. In another survey of 681 (17- to 22-year-old) students, 16.8% of the sample (28.6% boys, 4.8% girls) reported having sexual intercourse, and about half of these Students reported using a condom and experimenting with a same-sex partner (Chowdhury & Gill, 1994).

Tikoo et al. (1995) reported that older adolescents scored higher on reproductive knowledge and AIDS scales than did younger adolescents, but their knowledge was still limited. The maximum possible score on the knowledge scale was 15, and not one student scored the maximum. Performance was higher on the AIDS scale, with 33 students scoring the maximum possible 7 points. The average score on the knowledge scale was 4.19 and on the AIDS scale, 3.08. Boys scored higher than did girls on both scales.

Although teachers are crucial to the success of a National Sexuality Health Curriculum, many Indian teachers are opposed to the idea of sexuality education in schools. Even if a National Sexuality Education Curriculum becomes a reality, it may not change anything if the teachers do not want to deliver it. Srivastava, Nirupama, Chandra, and Jain (1992-93) reported that school teachers in rural India had limited knowledge about AIDS. Newspapers were mentioned by 60%, and 30% mentioned TV as the major source of information. Of the 182 teachers surveyed, 20% had not heard of AIDS. Many misconceptions regarding modes of transmission and the spread of disease existed among this group of teachers. The current study provides a preliminary report on the sexual behaviors of 10- to 17 attitudes and behaviors year-old Indian youths, the group most likely to be affected by the future spread of AIDS.

Method

Participants

The sample included 890 students from a public school in New Delhi, India. Grades 6 through 12 were surveyed. Each grade had eight sections of which four were selected randomly. The data were collected in July 1994. I administered the questionnaire in each classroom. At the beginning of each questionnaire-administration session, the aims of the survey and reason the respondents had been selected were explained. The students were asked to consult me if they had any problems or questions. The students were assured anonymity and were free to refuse to answer the questionnaire or any particular question(s) that they thought were invasive. Each class took approximately two class periods to complete the questionnaire (1 hour and 10 minutes). As a result of an expressed need, students were given a telephone number where they could receive anonymous information regarding human sexuality and AIDS.

Measures

The questionnaire involved 99 items in 2 parts. The first part consisted of 86 questions, and the second part, 12 questions specific to sexually active students. Question 99 asked for general feedback regarding the questionnaire. The questions pertained to demographics, knowledge, attitudes, and behaviors regarding human sexuality and AIDS. Twenty single items were used to assess attitudes toward sexuality; of these, four items (53-56) comprised the ATTSEX scale, which measured an individual's attitude toward premarital sex. Sixteen single items were used to gain insight into the respondents' behaviors.

Results

Analysis

The data were subjected to simple descriptive statistical analyses: Frequencies and t-tests were computed to search for and establish meaningful relationships. One-way analyses were conducted to give additional information about the relationship between the independent variables and the single items used to measure attitudes and behaviors. Reliability, alpha values) for the ATTSEX scale was generated post hoc and had a reliability coefficient of .70. The scale was additive, with a maximum possible score of 12 and a minimum score of 4.

Respondents

Of the 893 completed questionnaires, 890 were analyzed, as 3 students did not identify their gender. The mean age of the students completing the questionnaire was 13.46 years. Of the sample, 873 described themselves as Indian, with 1 student describing himself as a citizen of the world, 1 as Kuwaitian, and 15 giving no response. The gender breakdown was 45% female (n = 397) and 55% male (n = 493). Eighty-one percent of the students lived with their natural parents (of these, 8% had their grandparents living with them), another 7% lived with one parent, 5% lived with other relatives, and 7% did not respond to this question. The number of children each student lived with ranged from 0 to 5 (M = 2.43, SD = 1.21) children. All social classes were represented. The religious composition of the sample was 89% Hindu, 4% Sikh, 2% Muslim, 1% Christian, and 3% secular, and most participants rated religion as important or very important. The breakdown of students by grade was as follows: 186 (Grade 6), 117 (Grade 7), 119 (Grade 8), 101 (Grade 9), 117 (Grade 10), 134 (Grade 11), and 119 (Grade 12).

Attitudes

A quarter of the sample (27% girls, 23% boys) agreed with the statement "boys like sex more than girls," and about one third (28% girls, 34% boys) agreed with the statement "girls want love more." This suggests that the students believe girls to be more emotional and feelings oriented than boys. Very few students agreed (12% girls, 16% boys) with the statement "homosexual relationships are OK"; this could be because the students do not understand what being a homosexual means.

Most students (girls more than boys) had a traditional opinion toward sex outside of marriage. Of the sample, 51% of the girls and 34% of the boys disagreed with the statements "it is OK for a boyfriend and a girlfriend to have sex"; 51% of the girls and 42% of the boys disagreed with the statement that "it is OK for good friends to have sex"; 51% of the girls and 43% of the boys disagreed with the statement "sex is OK before marriage"; 36% of the girls and 30% of the boys disagreed with the statement "sex is OK if you plan to marry"; and 49% of the girls and 53% of the boys agreed that "sex is OK only if you are married." As the level of commitment in the relationship increases, so does their acceptance of premarital sexual behavior. On the ATTSEX scale the mean score for the sample was 6.66 (SD = 2.29), which indicates that the students neither disagreed nor agreed with the statements measuring permissive attitudes toward sex. Boys scored higher (M = 7.18, SD = 2.33) on the ATTSEX scale than did girls (M = 5.86, SD = 2.00), indicating that boys were more accepting of premarital sex than were girls.

About a quarter (22% girls, 28% boys) of the students agreed with the statement "information about birth control makes young people more likely to become sexually active" and about a third (32% girls, 42% of boys) with the statement "birth control would be used more often if it were easier to get." This suggests that these students do believe that information about sexuality would make them more likely to experiment with sexual behavior. This may, to some extent, explain the reason for suggesting 15.55 years as the age to start sex education.

Of the sample, 91% (238) of the girls and 85% (295) of the boys agreed that use of contraceptives is a responsibility that should be shared by both boys and girls. In response to the statement "if a girl becomes pregnant, she should--," 70% (187) of the girls and 68% (249) of the boys chose the option of marriage; abortion was selected by 10% (27) of the girls and 15% (54) of the boys. In response to the statement, "if a boy makes a girl pregnant, he should--," 90% (251) of the girls and 89% (329) of the boys chose the option of marriage; abortion was a choice for 3% (8) of the girls and 15% (19) of the boys. This discrepancy in responses between these two questions could be because the statement, "if a girl becomes pregnant, she should--," included as an additional option of being a single mother and raising the child; this alternative was selected by 8% of the boys and 9% of girls. In response to the statement concerning who should make the decision regarding the out come of an out-of-wedlock pregnancy, 33% (297) chose the doctor, 24% (210) selected both boy and girl, 11% (101) chose parents, 6% (51) chose only the girl, and 2% (19) chose only the boy.

Of the sample, 33% of the girls and 21% of the boys were in favor of receiving sex education at home from parents, and 30% of the girls and 38% of the boys were in favor of sex education in schools. In response to the question, "where would you prefer to receive sexuality education?" most students chose the doctor over their friends and parents. These findings suggest that there may be a need to include a course about delivery of sexuality education in the curriculum for medical students, as they are more likely to be sought by adolescents for counsel on sexual behaviors.

Behaviors

Of the sample, 77% (231) of the girls and 58% (214) of the boys reported that they did not know about the sexual activity of their friends, as conversations between students are almost always academic and discussion of sexuality and related behaviors is uncommon, if not absent. Of the sample, 80% (240 1 of the girls and 64% (233, of the boys reported never being sexually attracted to an adult, 88% (262) of the girls and 76% (247) of the boys reported never being sexually attracted to a boy, and 74% (193) of the girls 60% (218) of the boys reported never being sexually attracted to a girl. Of the sample, 7% (17) of the girls and 14% (48) of the boys reported masturbating, and 3% (8) of the girls and 7% (25) of the boys reported being raped. There may be some underreporting about masturbation and rape, as the younger age groups may not know the meaning of these terms.

Of the nine girls who reported pregnancy, five were from Grade 7, one was from Grade 8, two were from Grade 9, and one was from Grade 12. There is a possibility that the students in Grades 7 and 8 were more likely to say yes to being pregnant, not because they were pregnant but because they do not understand the meaning of being pregnant Above all, being a yes person is more appreciated in the Indian culture. Of the sample, 2% (7) of the girls and 7% (24) of the boys reported having sex for money, 1% (4) of the girls and 3% (13) of the boys reported having sex for drugs, 2% (7) of the girls and 2% (9) of the boys reported using drugs, 98% (280) of the girls and 94% (334) of the boys reported never drinking alcohol, and 1% (3) of the girls and 3% (8) of the boys reported having sexual intercourse. As 47% (134) of the girls and 62% (219) of the boys reported that they would use a sexual health clinic at school, and also, as few are experimenting with risky behavior, it may be cost efficient and beneficial to reach these students through the school system as opposed to no sexuality education in the schools, which is the present mandate.

The following responses were obtained to the open-ended question, "What does sex mean to you?"

sex = boy love for girl (Class 7)

sex means mixed male gamete to

female gamete (Class 8)

before marriage a cheap thing

(Class 8)

physical contact between boy and

girl (Class 9)

I think sex is OK or we can say

good after marriage. It is a type of

exercise. You should have it after

your marriage. And, also it is a

method to produce baby and

continue your generation. (Class 10)

I'm at that age in which my

knowledge about sex is very poor

and it seems to be very bad and

embarrassing activity. (Class 11)

It is an intimate pleasure shared by

two individuals of opposite sex and

should be only done if the

relationship between the two

individuals is everlasting. (Class 12)

In response to the question asking if they wanted to share any general feelings about the survey, a majority of the students stated that they wanted more information about human sexuality and AIDS.

Gender Differences

Significant gender differences were found in the attitudes of boys and girls. Gender differences regarding attitudes toward human sexuality are summarized in Table 1. Girls disagreed significantly with the statement that girls want love more; disagreed with the statements that it is OK for a boyfriend and a girlfriend to have sex, that it is OK for good friends to have sex, that sex is OK before marriage, and that sex is OK if you plan to marry, agreed more with the statement that it is best to start receiving sex education at home from parents; and were more conservative in their attitudes toward premarital sex than were boys.

Table 1
Gender Differences in Attitudes
                                     Girls'           Boys'
Variable                              mean    SD      mean    SD

Boys like sex more                    2.14    0.78    2.00    0,77
Girls want love                       2.05    0.85    2.23    0.78
Homosexual relationships OK           1.70    0.73    1.82    0.75
Information about birth control
makes people sexually active          2.01    0.80    2.07    0.81
Birth control used often
if easier to get                      2.24    0.82    2.39    0.77
Sex is OK for boy- and girlfriends    1.34    0.58    1.85    0.86
Sex is OK for good friends            1.36    0.65    1.67    0.80
Sex is OK before marriage             1.44    0.74    1.68    0.84
Sex is OK if plan to marry            1.78    0.86    2,00    0.88
Sex is OK if married                  2.49    0.82    2.53    0.76
ATTSEX scale                          5.86    2.00    7.18    2.33
Sex education at home                 2.16    0.94    1.78    0.83
Sex education at school               2.09    0.89    2.26    0.84

                                      t

Boys like sex more                    NS
Girls want love                      -2.79
Homosexual relationships OK           NS
Information about birth control
makes people sexually active          NS
Birth control used often
if easier to get                      NS
Sex is OK for boy- and girlfriends   -8.46
Sex is OK for good friends           -5.30
Sex is OK before marriage            -3.78
Sex is OK if plan to marry           -3.11
Sex is OK if married                  NS
ATTSEX scale                         -7.21
Sex education at home                 5.75
Sex education at school               NS

Note: Range of responses 1 = disagree, 2 neither, 3 = agree. The Bonferroni correction has been applied, and differences significant at p < .004 are reported.

The average age at puberty was 13.07 years, which is about a half year older than that of adolescents in other European countries. The average age when the students learned about human sexuality was 10.9 years. The sample reported a range from 3 to 26 years to start sex education (M = 15-55, SD = 4.28); there was a significant difference, t = -2.75, p [is less than] .01, between the genders. Girls reported a lower age to start sex education 14.99 years (SD = 3.69), whereas boys reported an age of 15.94 years (SD = 4.63) to start sex education. There was a significant difference, t = -3.84, p [is less than] .001, between the genders, with girls reporting 22-99 years and boys reporting 23.70 years as the age at which they would like to marry Respondents stated 1.88 (SD = 0.49) as the average number of children an ideal family should have, whereas the number was lower, at 1.65 (SD = 0.57) children, for their planned families.

Gender differences in response to statements measuring behaviors are summarized in Table 2. Boys were more likely than girls to report that their friends did more sexually; being attracted to an adult, a boy, or a girl; having an STD; and using the sexual health clime at school.

Table 2
Gender Differences in Behaviors

                           Girls'           Boys'
Variable                    mean    SD      mean    SD       t

Friends do more sexually    2.01    0.49    2.18    0.62    -3.64
Attracted to an adult       1.18    0.38    1.35    0.48    -4.97
Attracted to a boy          1.09    0.29    1.23    0.42    -4.67
Attracted to a girl         1.22    0.41    1.38    0.49    -4.36
Have masturbated            1.09    0.28    1.15    0.36     NS
Have been raped             1.03    0.17    1.07    0.26     NS
Had STD                     1.00    0.06    1.05    0.21    -3.57
Had sex for money           1.02    0.16    1.07    0-25     NS
Had sex for drugs           1.01    0.12    1.03    0.18     NS
Used IV drugs               1.03    0.16    1.02    0.15     NS
Drink alcohol               1.03    0.21    1.07    0.29     NS
Use sex health clinic       1.47    0.50    1.62    0.49    -3.69
Had sexual intercourse      1.01    0.11    1.03    0.17     NS

Note: Range of responses 1 no, 2 = don't know, 3 = yes. The Bonferroni correction has been applied, and differences significant at p < .004 are reported.

Boys who were involved with a romantic partner were more likely to have used alcohol, F = 9.25 (1, 292), p [is less than] .003. Girls who were involved with a romantic partner scored higher on the premarital sex scale, F = 6.66 (1, 221),p [is less than].002. Girls were conservative in reporting their own attitude, with very few admitting being attracted to an adult, a girl, or a boy. Boys who were less satisfied with themselves, measured by a single item, on the whole I am satisfied with myself, were more likely to use a sexual health clinic, F = 9.58 (1, 257), p [is less than] .002. Girls who were less satisfied with themselves, measured by a single item, on the whole I am satisfied with myself, were more likely to support sex education in schools, F = 4.37 (2, 182), p [is less than] .05.

Grade Differences

There were significant differences between the attitudes and behaviors of sixth through ninth grade and tenth through twelfth grade students. The sample was analyzed separately for boys and girls, as there were significant gender differences in responses, over and above the grade differences. The Grade 69 girls differed significantly from the Grade 10-12 students in response to the statements that boys like sex more than girls do, girls want love more than boys, information about birth control makes young people more likely to become sexually active, it is OK for you and a very good friend to have sex, sex is OK only if you plan to marry, sex is OK only if you are married, it is best to start receiving sex education at home from parents, there should be sex education in schools, ever being attracted to an adult, ever being attracted to a girl, having had sex for money, and using a sexual health clinic. Grade differences regarding attitudes are summarized in Table 3.

Table 3
Differences in Attitudes between
                                     Girls
Variable                              6-9    10-12      t

Boys like sex more                    1.73    2.52    -10.17
Girls want love more                  1.68    2.40      8.21
Homosexual relationships
are OK                                1.73    1.68     NS
Information about birth control
makes people sexually active          1.81    2.21    -4.35
Birth control used if easier to get   2.18    2.30     NS
Sex is OK for boy- and girlfriends    1.39    1.30     NS
Sex is OK for good friends            1.50    1.25     3.22
Sex is OK before marriage             1.47    1.43     NS
Sex is OK if plan to marry            1.99    1.56     4.32
Sex is OK if married                  2.20    2.75    -6.04)
ATTSEX scale                          6.24    5.55     NS
Sex education at home                 2.03    2.29    -2.65
Sex education in school               1.76    2.41    -6.56

                                     Boys
                                      6-9     10-12    t

Boys like sex more                    1.90    2.06     NS
Girls want love more                  2.08    2.33    -3.11
Homosexual relationships
are OK                                1.88    1.80     NS
Information about birth control
makes people sexually active          2.04    2.10     NS
Birth control used if easier to get   2.40    2.39     NS
Sex is OK for boy- and girlfriends    1.92    1.82     NS
Sex is OK for good friends            1.86    1.52     4.14
Sex is OK before marriage             1.73    1.67     NS
Sex is OK if plan to marry            2.23    1.77     5.25
Sex is OK if married                  2.40    2.58     NS
ATTSEX scale                          7.72    6.77     3.94
Sex education at home                 1.89    1.72     NS
Sex education in school               1.94    2.52    -6.94

Note: Range of responses 1 = disagree. 2 neither, 3 = agree. The Bonferroni correction has been applied, and differences significant at p < .002 are reported.

The Grade 6-9 boys differed significantly from the Grade 10-12 boys in response to the statements that girls want love more than sex, it is OK for you and a very good friend to have sex, sex is OK if you plan to marry, age at which sex education should begin, age at which they would like to marry, ever being attracted to a boy, having had sex for money, and on the attitude scale. Grade differences regarding behaviors are summarized in Table 4.

Table 4
Differences in Behaviors between Grades 6-9 and 10-12

                           Girls                   Boys
Variable                    6-9    10-12    t       6-9    10-12

Friends do more sexually    2.06    1.97    NS      2.27    2.10
Attracted to an adult       1.26    1.08    4.19    1.33    1.37
Attracted to a boy          1.08    1.09    NS      1.31    1.15
Attracted to a girl         1.32    1.09    4.62    1.34    1.44
Ever masturbated            1.05    1.11    NS      1.16    1.16
Been raped                  1.06    1.01    NS      1.12    1.04
Been pregnant               1.06    1.01    NS       --      --
Had abortion                1.05    1.01    NS       --      --
Had STD                     1.01    1.00    NS      1.06    1.04
Sex for money               1.05    1.00    NS      1.12    1.02
Sex for drugs               1.02    1.01    NS      1.06    1.02
Used IV drugs               1.04    1.01    NS      1.03    1.02
Drink alcohol               1.03    1.03    NS      1.09    1.05
Use sex health clinic       1.40    1.55    NS      1.61    1.62
Had sexual intercourse      1.02    1.01    NS      1.01    1.05

                             t

Friends do more sexually     NS
Attracted to an adult        NS
Attracted to a boy           3.61
Attracted to a girl          NS
Ever masturbated             NS
Been raped                   NS
Been pregnant                --
Had abortion                 --
Had STD                      NS
Sex for money                3.53
Sex for drugs                NS
Used IV drugs                NS
Drink alcohol                NS
Use sex health clinic        NS
Had sexual intercourse       NS

Note: Range of responses 1 no, 2 don't know, 3 = yes. The Bonferroni correction has been applied, and differences significant at p < .002 are reported.

A closer look at the distribution of students by grades in response to behavior items revealed that girls in Grade 7 were more likely to say Yes to being attracted to an adult (28/50 girls said yes), attracted to a girl (31/53 said yes), pregnant (5/9 said yes), have had am for money (617 said yes), ever used TV drugs (4/7 said yes), ever drunk alcohol (2/2 said yes), and having had sexual intercourse (2/3 said yes).

The Grades 6-9 differed significantly (p [is less than] .01) from Grades 10-12 , who agreed more with the statements that "boys like sex more than girls," "girls want love more than sex," "information about birth control makes young people more likely to be sexually active," "sex is OK if you are married," and "there should be sex education in schools." Grades 10-12 disagreed more with the statements, "it is OK for you and a good friend to have sex" and "sex is OK if you plan to marry." The students of Grades 10-12 suggested a year earlier for starting sexuality education (15.07 years) and a year later for marriage (23.97 years) in comparison to the students of Grades 69.

Discussion

Nonresponse rates ranged from 20-30% for some questions; this is not surprising, as students in lower grades have little or no information about questions pertaining to issues like sexual intercourse, oral sex, etc., and hence are totally naive about the terminology related with expression of human sexuality. Although the sample is from a co-ed school, discussion about issues related to human sexuality and AIDS is limited, if not nonexistent. Most talk between students is related to academics. Teachers and parents encourage excellence in school, but social activity between boys and girls is not encouraged, as demonstrated by the lack of reported sexual activity and experimentation in this sample. There is pressure on adolescents to be focused on academic achievement, as education and admissions to colleges and universities are age graded (there is an age limit). If students cannot be admitted into a college straight out of school, they will most likely be unable to get a regular college education, which is the aim of most adolescents. Also, changing majors is not a common practice. Starting in Grade 10, students have to make career decisions that have lifelong implications. These decisions are final by the tame students graduate from Grade 12. Competition is severe throughout the educational journey for an individual in India, leaving very lit, de fame for other social activities, including romantic involvements in or out of school.

Expression of sexuality as defined by students' attitudes toward premarital sex, use of birth control, homosexuality, and sex education tended toward neither agree nor disagree. The older students were more likely to agree with statements that were permissive of premarital sex and supported sex education in schools. A large number of boys and girls agreed with the statement that sex is OK only if you are married. These findings suggest that the younger Students have not formed definite opinions about what is an acceptable or unacceptable expression of sexuality. The older the students, the more likely they were to have formed definite opinions about right and wrong behaviors, which may put them at risk for AIDS, STDs, and unhealthy relationships. The younger students were more open to learn about sexuality, and this may indicate that a successful sexuality health curriculum would be one that starts in the middle school.

Overall, students did not perceive their friends as being more sexually active than themselves, and most reported minimal sexual experimentation. Most boys and girls reported not being attracted to others, using alcohol, or having sexual intercourse. Only 1% of the sample reported sexual activity. Many students, more girls than boys, reported being attracted to people of the same sex. It is possible that these girls are using the term attracted as being synonymous with admiration, which could be liking a person very much because he or she is good academically. This is a plausible explanation, as more boys reported being attracted to a boy, too. Another reason for low reports of attraction toward members of the opposite sex could be because students know that schools and society in general are not accepting of romance in schools. Also, they were more likely to deny being attracted, not because they were trying to be untruthful but because that is what they truly believe to be the behaviors of a good student. Chowdhury and Gill (1994), with a sample of 17- to 22-year-olds, reported that 28.6% of the boys and 4.8% of the girls were sexually active. This indicates a sharp increase in sexual experimentation among boys and girls as they enter college and universities. Because students' information is limited and often inaccurate, it is essential to educate adolescents in school so that they are prepared to make informed decisions and choices about whether to become sexually active. One reason that the Students: reported an average age of 15.6 years to begin learning sexuality information could be that reporting a younger age would reflect their interest in the subject of sex, which is thought of as dirty. This is in contrast to the desire expressed by students from all grades for more information about sex and AIDS.

There were some clear differences between the responses of girls' and boys attitudes and behaviors regarding expression of human sexuality. More girls favored receiving sexuality education at home from their parents. This may mean that there is also a need to educate parents regarding human sexuality and AIDS so that they can be accurate informants. Both genders favor sexuality education in schools, but boys favor it more than do girls. Overall, the attitudes and behaviors of the students are still more traditional than those of their counterparts in developed nations. Another important finding is that doctors may need to be trained to deliver sexuality education, as they were most likely to be sought as a source for information. The limited information about human sexuality and ADDS is scary, given the predicted rise in the number of AIDS cases in the developing countries, particularly in Southeast Asia. In tins case, ignorance is not bliss.

India approaches issues regarding sexuality with extreme caution and traditional conservatism. But, again, one needs to be cautious when comparing these age groups, as the Indian sample was of school students. Chowdbury and Gill (1994) reported increases in sexual experimentation in college students in India. Misinformation is widespread among Indian adolescents, too; the only difference is that there is a lack of experimentation with behaviors that may put them at risk for contracting the disease.

These surveys reveal that although awareness about AIDS is universal, there are still many misconceptions regarding the modes of transmission of HIV and understanding of the symptoms. Most populations surveyed would like more information about human sexuality and AIDS. It is also a cause for concern that many adolescents are aware of the disease but do not care to alter their behavior, as they do not feel that they are at risk. Indian adolescents do not seem to be very different in their attitudes when compared with their counterparts in many other countries, but they are definitely less sexually active, which is good, given that their knowledge of human sexuality and AIDS is limited.

The findings reported in this study stress the need to carry out similar surveys for all age groups in India so that everyone can be educated about the disease and to help prevent its spread. This study is a small contribution toward the need for information about the behavior of adolescents. Future researchers could build upon the current research by including parents and teachers in surveys to learn more about the attitudes and behaviors of the people who oppose the national sexual health program. Studies specifically addressing AIDS-related attitudes and risk behaviors are clearly needed. Also, from experience in America, we know that deliverers of sexuality education are crucial to the success of these programs (Rodriguez, Young, Renfro, Asencio, & Haffner, 1995-96). Hence, the success of any national sexual health program depends on preparing a group of teachers who are sensitive to the needs of adolescents and who can deliver information objectively.

The results of this study answer some questions raised by researchers like Bollinger et al. (1995, and Jain et al. (1994) about the existing knowledge, attitudes, and behaviors of Indian adolescents so that effective educational and prevention-oriented programs can be undertaken. As resources are limited, a comprehensive plan for preventing the spread of the disease would be one that uses the existing body of research information and available resources optimally.

As professionals working with families, we should provide information about human sexuality from cognitive, behavioral, and affective domains in an integrated manner to adolescents. There is no simple solution to the problem of AIDS. One (and so far the only) way is to educate children at home and school to empower them to reduce their risk of contracting HIV.

References

Bertrand, J. T., Makani, B., Hassig, S. E., & Niwembo, K. L. (1991). AIDS-related knowledge, sexual behavior, and condom use among men and women in Kinshasa, Zaire. American Journal of Public Health, 81, 53-58.

Bollinger, R. C., Tripathy, S. P., & Quinn, T. C. (1995). The Human Immunodeficiency Virus epidemic in India current magnitude and future projections. Medicine, 74, 97-106.

Center for Disease Control. (1995). World News Tonight with Peter Jennings, ABC News, November.

Chowdhury, S., & Gill, F. P. T. (1993). A study of knowledge, beliefs, and attitudes regarding AIDS, STDs and human sexuality among senior secondary students in Delhi. Unpublished manuscript.

Chowdhury, S., & Gill, F. T. P. (1994). Knowledge of college students regarding AIDS. Unpublished manuscript.

Cox, F. D. (1994). The AIDS booklet. Dubuque, IA: Brown & Benchmark

Danziger, R. (1994). The social impact of HIV/AIDS in developing countries. Social Science Medicine, 39, 905-917.

Family Planning Association of India. (1992). Challenges, strategic plan 1992-2000, 3.

Jacob, K. S. Jayakumari, H., John, J. K., & John, J. J. (1989). Awareness of AIDS in India: Effect of public education through the mass media. British Medical Journal 299, 721.

Jain. M. K. John. T. J., & Keusch, G. T. 1994. A review of human immunodeficiency virus infection in India. Journal of Acquired Immune Deficiency Syndromes, 1185-1194.

National AIDS Control Program. (1993). Country scenario: An update, April 1993. National AIDS Control Organization, Ministry of Health and Family Welfare, Government of India, 1.

Ndeki, S. S., Klepp, K. I., Seha, A. M., & Leshabari, M. T. (1994). Exposure to HIV/ AIDS information, AIDS knowledge, perceived risk and attitudes toward people with AIDS among primary-school children in Tanzania. AIDS Care, 6, 183-191.

Pathak, R. (1994, January 31). The new generation. India Today, 48-51.

Porter. S. B. (1993). Public knowledge and attitudes about AIDS among adults in Calcutta India. AIDS Care, 5, 169-176.

Rodriguez, M., Young, R., Renfro, S., Asencio, M., & Haffner, D. W. (1995-96). Teaching our teachers to teach: A SIECUS study on training and preparation for HIV/AIDS prevention and sexuality education. SIECUS Report, 24(2), 15-23.

Sex Education Counseling Research Training and Therapy Department of FPAI. (1988). Attitudes and perceptions of educated, urban youth to marriage and sex. Unpublished manuscript.

SIECUS Report. (1994, August/September). National commission on adolescent health, 24.

Srivastava, V. K., Nirupama, S., Chandra, R., & Jain, V. C. (1992-93). AIDS awareness amongst school teachers in a rural area in India. Asia-Pacific Journal of Public Health, 6, 16-17.

Stine, G. J. (1995). AIDS update 1994-95. Englewood Cliffs, NJ: Prentice Hall.

Tikoo, M., Bollman, S. R., & Bergen, M. B. (1995). Knowledge level of youth in India regarding human sexuality and AIDS. Journal of Sex and Marital Therapy, 21, 246-252.

Manuscript accepted June 27, 1996

The data for this article were generated from the Ph.D. dissertation, "Survey of Adolescent Knowledge, Attitudes, and Behaviors Regarding Human Sexuality and AIDS in India," by Minsakshi Tikoo, under the direction of Drs, Stephan R. Bollman, AL Betsy Bergen, and Walter R. Schumm, and with additional assistance from Farrell J. Webb. This study was possible because of the cooperation from students and teachers of Kendriya Vidyalaya, New Mehrauli Road. I express my deepest gratitude to them.

For reprints, write to Minakshi Tikoo, Ph.D., CFLE, 319 Justin Hall, School of Family Studies and Human Services, College of Human Ecology, Kansas State University, Manhattan, KS 66506. Fax: [phone]. Phone: [phone]. E-mail: [e-mail].