Gender inequality and traditional social norms as predictors of risky sex among men in the north Indian states of Uttar Pradesh and Uttarakhand: Quantitative and qualitative analyses

Quantitative data from the National Family Health Survey (NFHS-3) and qualitative data from an NIH-funded study in the north Indian states of Uttar Pradesh and Uttarakhand were used to examine the relationship between men's risky sex (non-marital and unprotected sex) and their gender equality attitudes and expressed social norms. Gender equality dimensions in the quantitative analysis were developed based on men's attitudes towards wife-beating, feelings regarding wives ability to refuse sex, history of family violence, and views on whether women had the right to make household decisions and have financial autonomy. Logistic regression models were fit to explore the influence of gender equality dimensions on reported non-marital sex and condom use. Qualitative analysis explored how men's gender attitudes and expressed social norms were related to their risky sex. Quantitative analysis indicated that men who were more likely to report non-marital sex were those who had a history of family violence [OR=1.83; 95% CI=(1.05-3.17) for married men; OR=1.93; 95% CI=(1.44-2.59) for unmarried men], felt that wife-beating was acceptable [OR=1.93; 95% CI=(1.10-3.38) for married men], and felt that women should not have the right to refuse sex [OR=2.17; 95% CI=(1.05-4.48) for married men]. Men who were more likely to report using condoms during nonmarital sex were those who felt that wife-beating was never acceptable, compared to men who felt that wife-beating was acceptable [OR=2.13; 95% CI=(1.35-3.36)]. Qualitative analysis revealed that men felt that women are sexually insatiable, should have no say over their own sexual needs, and be dependent on men to be sexually gratified. Men also indicated that certain restrictive social norms drove them to more, rather than less, non-marital sex. Men who reported no or inconsistent condom use felt that condoms prevented them from having "real" sex, that women did not have the right to request men to use condoms or to purchase condoms, and that men had the right to force women to have unprotected sex. Interventions that seek to curb the spread of STIs and HIV in India through reducing men's risky sex should promote a redefinition of men's traditional masculinity norms to incorporate acceptance of gender equality and prevention of violence against women.