Introduction
Individuals or couples’ ability to pursue a fulfilling and safe sex life is central to achieving sexual health. Sexual behavior is one of the important components of close relationship and emotional well-being. Marital partnership is the most socially accepted framework for sexual activity and as sex and marriage are legally and morally related, marital sex is not widely regarded by many cultures as a social issue. Many factors contribute to the frequency of sexual activity among married people like the duration of the marriage, physical health, mental well-being, life events, sociocultural beliefs, and many more.
No umbrella solution works everywhere for the promotion of sexual well-being and no single-component strategy works anywhere. We need to learn not only whether the strategies work but also why and how they work in different social contexts. Before starting any intervention, the baseline characteristics need to be explored adequately to identify the deviation from the basic. The South Asian region has relatively homogenous sociocultural settings, however not much research has been done about sexual activity among married couples. Also, there is poor help-seeking behavior among the couples of this region due to various reasons like stigma, cultural factors, regarding sex as a taboo, and so on. This has led to a lacuna in the development of culture-based intervention strategies in this region. Surprisingly, no study has been found exploring the baseline sexual contact frequency and country to country comparison is not feasible. Considering this, the current study was planned to see the frequency of baseline sexual intercourse among the residents of 3 socioculturally similar nations of the South-East Asian region (Bangladesh, India, and Nepal). In this study, sexual contact has been used as a synonym for sexual intercourse.
Methods
Study Setting and Data Collection
This cross-sectional study took place in April 2020 among individuals from 3 countries in South-East Asia (Bangladesh, India, and Nepal). We conducted the study during the COVID-19 lockdown regarding the sexual habit of the residents of the 3 countries. The research was performed using an online survey. In conjunction with all the researchers from these 3 countries, a questionnaire was generated in English using Google Forms. A convenient sampling technique was applied, and it addressed the individuals who understood English. The questionnaire link was forwarded to the associates of all investigators, and the respondents were asked to forward or post the links between their contact groups. Clicking on the link to the questionnaire, circulated during the study, and blinked a screen description of the study, followed by the consent form. Included in the study were participants aged 18 years and over, married and living with their partners, consenting to participate in the survey, and being able to understand English. After agreeing with the terms and conditions of the study, the questionnaire became available. Data were collected between April 3, 2020 and April 15, 2020. One of the investigators had done data cleaning, and a second investigator cross-checked it. Analysis of the data was performed using version 26 of IBM SPSS.
The Questionnaire
Section A: Sociodemographic variables consisted of age, sex, educational qualification, occupation, resident country, family type, the current status of living, number of children, any physical diseases, psychiatric disorder, any sexual dysfunction, medication history, and substance abuse.
Section B: Sexual history consisted of the duration of the marriage, mode of marriage, and usual frequency of sexual intercourse in a week and a month.
Ethics
This study was conducted during the lockdown period of COVID-19 pandemic. Therefore, a formal ethical clearance was not possible to seek as all the 3 countries were going through the emergency situation. However, other ethical aspects were duly maintained. Data were collected anonymously and voluntary basis. The ethical aspects like informed consent and confidentiality were ensured.
Results
A total of 120 respondents from the 3 South-East Asian countries (Bangladesh, India and Nepal) responded and were analyzed. The mean (±SD) age of the respondents was 35.42 (± 5.73) years ranging from 20 to 64 years. All the respondents had at least graduation and 46.7%, 38.3%, and 15% of respondents participated from India, Nepal, and Bangladesh, respectively. The details of the demography have been mentioned in our initial article of the project. Our findings on the effect of the COVID-19 pandemic on sexual life were published earlier. In this article, baseline sexual habits have been discussed.
About 25% of participants from India have sexual activity once a week and almost 33.3% of respondents from Bangladesh have sexual intercourse with their spouses once a week. Approximately 30.4% of respondents from Nepal shared that they usually have sexual intercourse twice a week. Nepalese sample populations also have shown higher sexual activities compared to Indian and Bangladeshi respondents, such as about 8.7% of respondents have sexual activities 5 times a week. The mean weekly sexual activity among the Nepalese is also high, 2.70, as compared to Bangladeshi and Indian samples whose weekly sexual activity are 2.32 and 1.82, respectively (Table 1). The distribution of sexual intercourse in a month is mentioned in Table 2.
Discussion
This study aimed to see the frequency of sexual contacts among the residents of 3 South Asian countries (Bangladesh, India, and Nepal). Sexual activity is influenced by the sociocultural and environmental factors surrounding the individuals. This study found a variety of sexual intercourse frequencies among married couples in Bangladesh, India, and Nepal. The mean of sexual intercourse in a week was the highest in Nepal (2.70 ± 1.99), followed by Bangladesh (2.32 ± 1.53) and then India (1.82 ± 1.68).
Sexuality in Bangladesh is affected by the cultural and traditional context of the country., Sexual behavior research is limited and was almost prohibited until recently, as the country is considered to some extent a puritan society, where the subject is considered taboo., Khan et al studied the sexual behavior of married women in Bangladesh that reported that most brides lack sufficient sexual knowledge at the time of marriage which affected their early sexual behavior; however, despite the taboo surrounding sexuality, many women were able to communicate with their husbands regarding their sexual interactions and most women enjoy their sexual life. Nevertheless, the study revealed that 50% of women did not like expressing their sexual desires to their husbands, while others would suppress their desires due to feeling shame in admitting to having them. Whereas, Uddin compared sexual intercourse frequency between Muslim and Santal in rural Bangladesh, and reported an average of 11.42 times/month for Muslims and a lower rate of 8.70 times/month for Santal couples, highlighting the difference in sexual behavior between communities living in the same geographic area.
The concept of sexuality has evolved over time in India, influenced by different cultures, rulers, and religions. Currently, the Indian community is considered to have conservative attitudes toward sex. A study reported, decrease of sexual excitement after first years of marriage, due to the birth of children, and the stress of life and family problems, older age group reported having sexual intercourse as an essential activity rather than personal interest. When studying sexual behavior among married women in North India, Avasthi et al reported similar findings of that of Khan et al in Bangladesh. The study reported that although most women expressed their satisfaction with their sexual life, almost half the sample reported waiting for their husband to initiate sexual activity.
In Nepal, like other South-Eastern Asian countries, where marriage is nearly universal, sexual activity and sexuality subjects are not discussed openly, and sex is considered a private affair between married couples. In the report about Chetri-Brahmin women revealed that the sample referred to marital sexual activity as a duty rather than a volitional experience, and the wife can be replaced by a co-wife if she refused sexual activity with her husband. The study also reported a mean of 7.0 times/month of sexual intercourse among the respondents.
From the literature, it is clear that the sexual activity of married couples varies among different ethnic and religious groups within India, Nepal, and Bangladesh, despite that those countries share the universal concept of marriage and conservative attitude toward sexuality.
This study reveals low sexual inactivity among married couples; 5.6%, 23.2%, 13% of respondents of Bangladesh, India, and Nepal, respectively, reported not having sexual activity in a week, with India having most sexual inactivity reported (Table 1). However, sexual activity or inactivity is not easy to be measured, due to the impossibility of determining if the period of data collection is representative of the couple’s normal sexual habits, or if the status of the couple sexual inactivity is temporal. Nevertheless, asking respondents to report on their sexual activity on a recent short period of time has the advantage of them being able to recall and provide accurate information than for longer periods.,
The strength of this study is that this is a cross-country study and we have included a homogenous sample of married people only. As sex has always been seen and discussed as a subject of taboo in all the 3 nations, the respondents giving responses over an online survey is an important point to be noted. Hence, planning further research using an online form where personal identity is not disclosed might be very handy in breaking the barrier of communication, minimizing socially desirable responses, and reaching out to many people in this part of the world. Possibly, this is the first study exploring the frequency of sexual intercourse across the 3 Asian countries.
There are several limitations to this study. The study was conducted during the early phase of COVID-19 lockdown period using a convenient sampling technique. The study was in English language and only included respondents with Internet literacy. Every country’s limited sample size is not representative, and thus cannot be extrapolated at a larger level. Only married people living with spouses were assessed. Thus, the generalization of the study result warrants cautious interpretations. As we only took general data for a week so it may not be representative of their sexual activity. Also, there is a possibility of self-reporting bias as Fenton et al argues, when it comes to self-reporting the frequency of sexual activity, men tend to over-report, whereas women tend to underreport their sexual activity, due to social desirability bias. However, the use of an online questionnaire might have reduced the overreporting and underreporting in this study.
Conclusion
This study revealed very baseline and preliminary excerpts of sexual intercourse habit among the residents of the 3 South Asian countries. There is geographical variation in sexual contacts. Further, large-scale studies not only looking at the sexual activity but also at the sexual well-being should be planned with validated and contextualized questionnaires in this region.
Declaration of Conflicting Interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The authors received no financial support for the research, authorship, and/or publication of this article.
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