1. Introduction

Human beings are sexual beings throughout their entire lives[1]. According to Freud; Maslow[2] states that “We are sexual from birth, and sexual expression is a basic human need throughout our lives”. The youth aged 25 years and below constitute 64% of Africa's population[3] while one in every Kenyan is an adolescent[4]. The Kenya National Youth Policy[5],[6] defines a youth as one aged between 15 - 30 years. This takes into account the physical, psychological, cultural, social, biological and political aspects, which explain the Kenyan youth situation. The youth in Kenya account for about 32% of the population or 9.1 million. Often the youth experience gradual movement towards heterosexual relationships which can lead to sexual activity[7]. Culture fundamentally affects sexuality and fertility by creating values, norms, and expectations about sexual relationships, roles and behavior[8]. Furthermore, it has been observed that there has been a replacement of the original African extended family by the Western nuclear family[9] ,[10]. In effect, this seems to have reduced the supervision and monitoring of youth activities including sexual behaviors by parents as well as close relatives[11],[12].

Studies on adolescent sexual behaviour worldwide show that young people's premarital sexual encounters are generally unplanned, infrequent and sporadic, a pattern that pre-disposes the youth to unwanted pregnancy and sexually transmitted infections[13]. In sub-Saharan Africa, 7.4% of all 15–24 years aged youth were infected with HIV in 1997, mainly thorough unprotected heterosexualintercourse[14],[15].

In Africa, most of the documented traditional ethnic groups instituted strict social and physical control measures especially for the behaviour of the young people[10]. They safeguarded the sexual behaviour of the young people until when they entered into marriage[9],[17]. Both pre-marital sex and premarital pregnancy were heavily punished[1]. Despite the social institution of religion featuring as an important determinant of indiscriminate sex in Kenya[4],[1] African traditional moral codes have been eroded and the concept of abstinence not fully adopted, further compromising sexual behavior[18]. Due to the influence of mass media’s presentation of sex as exciting and risk-free, an increasing number of unmarried youth (including YWD) are becoming sexually active at an early age. Fifty-two percent of the Kenyan youth aged between 15–19 years are sexually active and specifically 39% and 65% of unmarried Kenyan girls and boys respectively, have had sexual intercourse[19].

In parts of East and Central Africa, traditional rituals of initiation prepared young people for their adult roles including education on the responsibilities of sex, marriage and child rearing. In this context, sexuality serves, “…as a source of relations of kinship and affinity thereby the basis of solidarity, reciprocity and co-operation”[20]. Since sexuality contributed to social cohesion, communities developed “rules” concerning the expression of sexuality as well as mechanisms for controlling sexual behavior[20],[21].

In the contemporary society there are conflicting messages about youth sexuality, with the promotion of sexual involvement on one hand and on the other extreme urging of chastity[15]. This confusion makes the youth feel guilty, uncertain or indecisive about sexuality. Coupled with the harsh reality that many parents are uncomfortable discussing sexuality with their children, a role that has been left to schools already limited by the current debates on sex education[22]. Given the youth’s knowledge level on prevention and control of risks of unwanted pregnancies and STIs/ HIV infections, there is concern over their continued unsafe sexual practices and the associated morbidity.

In the face of the AIDS crisis in Kenya, the YWD like other Kenyans are increasingly being looked upon to play an important role towards fighting the pandemic, which is fast ravaging Kenya’s youthful population. Kenya occupies 5th position on the UNAIDS’ world HIV prevalence rankings[23]. Therefore, this paper describes the sexual knowledge, attitude and the factors influencing practice among the YWD in Bungoma district in Western Province, Kenya. It also discusses the social and policy context of YWD sexuality in Kenya.

2. Problem Statement

In recent years, important changes in public policies and attitudes have resulted in improved opportunities for people with physical disabilities. Now, people living with disabilities are required to occupy their rightful place in society as the equals of non-disabled people. There are indications that adolescents (including YWD) sexual behaviour worldwide and premarital sexual encounters are generally unplanned, infrequent and sporadic, a pattern that pre-disposes the youth to unwanted pregnancy and sexually transmitted infections. Unfortunately, societal attitudes have changed less in regard to sexuality and disability. Even today, many people refuse to acknowledge the fact that the youths with disabilities like all other people have sexual feelings, needs, and desires, regardless of their physical disability.

As a result, many young people who live with disabilities do not receive sex education, reproductive health services and other related guidance, either in school or at home. This exposes them to the risk of contracting not only HIV/AIDS but also other sexually transmitted diseases. The study intended to answer the following research questions: What were the levels of knowledge on sexuality among YWD, what were the sources of information on sexuality among YWD, What were the perceived risks among sexually active YWD and which were the contraceptive methods used among YWD.

3. Research Site and Methodology

Research Site

According to the District Development plan, 2005 – 2010[24], Bungoma District is one of the eight districts of Western Province. It lies at the Northern tip of Western Province and borders Mt. Elgon District to the Northwest, TransNzoia District to North, Kakamega District to the East, Butere/Mumias District to the Southeast, Busia to the West and Teso District to the Southwest. The district borders the Republic of Uganda at the Northwestern point town of Lwakhakha. The district lies between latitude 00 25.3’ and 00 53.2’ North and longitude 340 21.4’ and 350 04’ East. It covers an area of 2,068 km2, which is about 25 per cent of the total area of the province. An analysis of the population structure reveals a largely youthful population, the proportion being as high as 72.1% between the ages of 0-24.

Problems affecting people with disabilities (PWDs) include abandonment of PWDs, poverty, lack of shelter and inaccessibility to health care services. With regard to youth and children, problems identified include high rates of unemployment, school drop outs, early marriages and teenage pregnancies. The above problems have contributed to high HIV/AIDs prevalence in the district. One of the reproductive health (RH) concerns that have continued to affect a large population of Kenyans in their reproductive ages is STI/HIV/AIDS. In Bungoma district HIV prevalence is of great concern. In year 2000, HIV prevalence rate was reported to be between 20-30% way above the national prevalence of 14% reported in the same period. Between 50% of hospital beds in Bungoma district are occupied by HIV/AIDS patients. The culture, beliefs and poverty in the community are some of the major factors that have contributed to rise in infection rates in the district.

Methodology

In this study a semi-structured interview guide was used to gather data from a total of 20 respondents (YWD) 10 males and 10 females aged between 15–30 years, selected through simple random cluster sampling. The interview guide focused on the respondents’ background information; knowledge of contraceptive services; contraceptive attitude; contraceptive practice; and other aspects of sexuality. Data was analyzed using the Statistical Package for Social Sciences (SPSS) computer software package.

Twelve key informant interviews with parents, guardians, policy makers and health service providers purposively selected were conducted using interview guides and focused on youth sexual and reproductive health challenges; adult attitude and communication regarding youth sexuality and contraception; and national and institutional policies on youth contraception. Six informal conversational interviews with parents, guardians, local administration and the youth with disabilities focused on societal attitudes towards YWD sexuality and contraception.

4. Results and Discussions

4.1. Results

Background characteristics

The mean age of the sample population was 22 years. Over 83% were single, 5% divorced or separated and only 2% did not respond to the question. The high percentage of the unmarried was attributed to the fact that they were disabled and therefore could not get a suitable partner for marriage. Among the Luhyia culture disability is view as a curse and therefore a PWD is discriminated upon in many ways including marriage. This explains the societal attitudes towards people with disabilities among African societies. When asked why she was not married, Anyango (not real name) said thus:

“In this society girls with disabilities are not viewed as good wives because they cannot perform certain chores that are expected of wives”.

Another respondent Mukangala (not real Name) stated that:

“Because of my disability girls and the society at large do not regard me as a good husband since I cannot perform certain duties as an able bodied person”.

Knowledge of sexuality

Results indicate that 70% of the respondents (YWD) did not understand what sexuality means. Only 20% said “It is the sexual relationship between male and female. Another 10% said it was about sexual intercourse. From the responses above it is quite clear that sexuality issues were defined within the parameters of sexual relationship. This particular perception of sexuality being seen in terms of sexual relations is widespread where the study indicated that young people often have less access to information services and resources than those who are older. They further argued that one of the most important reasons why young people are denied adequate access to information, sexual health services and protective resources such as condoms, derives from the stereotypical and often contradictory ways in which they are viewed. Many adults have difficulties acknowledging adolescents as sexual beings and therefore adolescents must be controlled and restrained[25]. Majority of the respondents 55% indicated that though they knew of sexually transmitted infections (STI) such as Gonorrhea, Syphilis, HIV/AIDS and others they did not get that information from qualified health workers. They mainly got that information from their peers. This indicates the need to ensure that reproductive health information gets to the YWD particularly in rural areas through trained health personnel considering that they were sexually active as well as vulnerable and therefore likely to be exposed to STI.

When asked whether they knew of anyone one contraceptive method available in the market only 30% had knowledge of at least one contraceptive method available in the market. 65% did not know of any contraceptive method in the market. 5% did not respond. It emerged that the main sources of this information or knowledge (among the 30%) were mainly through the media, peers and educational institutions. During the interviews with the parents of YWD many parents/guardians reported reluctance to discuss relating to sexuality with their children particularly the YWD. They gave various reasons for reluctance including their disability. One parent, Mr. Masinde (not real name) reported:

“Our Luhyia culture does not allow parents to discuss such issues with children particularly a child with a disability since nobody will want to marry such a child”. It was interesting to note that similar arguments were given by 60% of the parents we held discussions with. This response confirmed that YWD are not viewed as people who have sexual needs so as to be given sexual information. It appears that some parents thought that information relating to sexual was meant for marriage. In another case one parent indicated that he would be uncomfortable with anyone giving his daughter such information since no one would want to befriend or marry her.

Sources of sexual information among YWD

The widely acknowledged source of sexuality information was the teachers (40%), television (30%), magazine (20%) and family members other than their parents (10%). None of the respondents mentioned church leaders or their parents. This finding is similar to the findings of a study in Ontario which found that 89% of adolescents felt that it was important for them to receive sexual health education[15]. From a list of six possible sources; the adolescents rated the school as their most preferred source of sexual health information, followed by friends and family members.

Eighty-five percent of the YWD affirmed present and future need for youth contraceptive services. 60% of the YWD had a negative attitude towards youth contraception. Data revealed that the basis of this perception was not definite facts or real life experiences, but rather mere hearsay. Asked how and why they thought so they said they had been told by their perceived knowledgeable friends that it was risky to use contraceptives. Others (40%) attributed it to the perceived health risks and the notion that the practice promotes promiscuity. Ironically, some opponents were current modern contraceptive users. Adult opinions on YWD contraception also varied from full support of effective youth contraception for service-seekers to total opposition of the issue as inappropriate. There are, also, moderates who advise youth contraception only under very special circumstances, such as pregnancy and STI counseling. Eighty three percent (83%) of the YWD favored health institutions i.e. hospital/dispensary and the family planning clinic as ideal service points. In terms of accessibility of currently available services to the YWD, only 20% were convinced the services were accessible, 10% thought they were only sometimes adequate and 70% felt they were hardly ever accessible.

Sexual Behaviour among YWD

Sixty five percent (65%) of the YWD were sexually experienced, with most of their first sexual experiences occurring between the age bracket of 12- 15 years age group: 70% of these were sexually active, with 80% engaging in regular sexual encounters and 30% maintaining single partner sexual encounters. Of those who engaged in regular sexual encounters 70% did not regularly use condoms during sexual encounters. The main motivational factors for engagement in sex were pleasure (75%); material gain (20%) and obligation (5%).

About 90% of the YWD acknowledged the risks in sexual relationships. Of these, 80% viewed STI/HIV as the greatest risk, while 15% considered unwanted pregnancy as the greatest risk. Only 5% recognized abortion and psychological problems as main risks. Although it was noted that about 55% of the YWD believe that abstinence is the main measure one can take against the identified risks, followed by (35%) use of condoms and 10% for other practices such as faithfulness between sexual partners one respondent asked a question: “In this era who can totally abstain from sex given that there is a lot of explicit materials on sexuality in the media?”

The above question confirms that abstinence is not one of the easiest options compared to other options. The youth further argued that with explicit materials that provoke sexual emotions there is a likelihood of YWD engaging sex that abstaining.

Contraceptive Use among YWD

Only five percent (5%) of the YWD had ever-used a contraceptive, and the trend in the common methods ever-used indicates popularity of the male condom. Surprisingly, only 5% of the respondents had used a contraceptive method during their first sexual encounter. Only 10% of the YWD are currently using a contraceptive method. It emerged that most popular used method use was the male condom among the respondents. The respondents argued that the main reasons for using the male condom was based on its effectiveness in preventing pregnancy (50%), ease of use (30%) disease prevention (10%) and affordability (10%).

4.2. Discussion

Sexual behavior of young people has been a source of concern to societies worldwide[16]. From the above results, 70% of the YWD did not understand what sexuality means. Only 20% viewed sexuality as a relationship between male and female while 10% said it was about sexual intercourse. From the results it is quite clear that sexuality issues were defined within the parameters of sexual relationship. This particular perception of sexuality among the YWD being seen in terms of sexual relations is widespread. The study indicated that young people particularly YWD often have less access to information services and resources than those who are older and they further say that one of the most important reasons why young people are denied adequate access to information, sexual health services and protective resources such as condoms, derives from the stereotypical and often contradictory ways in which they are viewed. Many adults have difficult acknowledging YWD as sexual beings and therefore they must be controlled and restrained. This is likely to expose them to STI and in particular HIV/AIDS. The YWD in most African societies are marginalized in terms of accessing information and therefore face numerous reproductive health challenges due to their disability.

Most YWD got information relating to sexuality from educational institutions and in particular the teachers, media, peers and other members of their families other than their parents. It was amazing to note that parents featured very little as sources of this information yet parents are supposed to socialize and prepare their children for life. It emerged that the YWD were not comfortable to consult informally with adults on sexual issues. Instead they consulted their peers, media, teachers, as well as other members of their families. Reasons given for this included not knowing how to approach the issue and not wanting to alert the disapproving adults and specifically the immediate parents of the youth's sexual activities. Consequently the ‘informed’ peer was then viewed as a better source of information, knowledge and counsel because of assumed confidentiality and non-judgment.

Furthermore, few parents/guardians were not comfortable discussing matters of sexuality with their children particularly those with disabilities (YWD). They deemed issues of sexuality to be more appropriately discussed in a reactive rather than proactive fashion, especially when the YWD was found in a sex-related problem such as sexually transmitted infection or unwanted pregnancy. These findings agreed with earlier findings by[26] who concluded that parents often prefer sex-related issues to be addressed by schools. However, the challenge here was that the formal education system to which the responsibility of sex education has been left was also still limited by the current debate on what aspect of family life education should be taught, to whom, and by whom. On the other hand most YWD were not likely to attend formal schools and therefore most were likely to miss accessing this information. In the meantime alternative sources of information were sought in the form of inadequately informed or misinformed peers.

There was lack of information on sex related issues by the YWD, This was an indicator that there were still a marked lack of factual information that promotes suspicion and unfounded myths. The mystery around and undue restrictions on sex related issues contributed to negative attitudes towards sex which is a basic human need.

This study revealed that most YWD were sexually experienced, with most of their first sexual experiences occurring within the 12-15 years age bracket. Many were sexually active and engaged in regular sexual encounters with regular sexual partners showing a relatively stable pattern of relationships. More importantly, the YWD were aware of consequences of sexual relationships such as unwanted pregnancies and STI/HIV infections. They also had knowledge of precautions for these risks as revealed by the analysis of choice of contraceptive method against reason for choice. For instance there was preference for the male condom which was primarily chosen for disease and pregnancy prevention, dual roles that it can serve well if used appropriately. However, the concern here was how can the YWD get access to various choices available in the market? More worrying was the revelation that majority of those who engaged in sex regularly did not use condoms. This was likely to expose the YWD to Sexual Transmitted Infections such as HIV/AIDS, among other infections.

5. Conclusions and Recommendations

This paper described the different aspects of sexuality and YWD in a rural district of Bungoma in Western Province in Kenya. Findings revealed that there existed a wide gap between knowledge and practice among YWD. The YWD are ignorant on pertinent issues on sexuality. The YWD are sexually engaged in risky sexual behaviours since very insignificant number utilize contraceptives. Further the study concludes that family members play a minimal role in transmitting sexuality information. Therefore, there was need to review and revise policies and practices regarding reproductive health, sexuality and family life education as it relates to YWD in rural Kenya where majority of YWD live. Owing to the fact that YWD spent almost over three quarters of their time in school, educational institutions (pre-primary to secondary) come in handy to offer sexuality education. In complementing the family and parents, the education systems in Kenya must vigorously incorporate in their curriculum, facilitate and implement Comprehensive Sexuality education. There is need for the government and other stakeholders in the health sector to involve YWD in planning and implementation of reproductive health projects in the district so as to empower them on their reproductive health rights.

ACKNOWLEDGEMENTS

We wish to acknowledge the contributions made by our informants from the study area especially our key informants. Gratitude also goes to our postgraduate students and research assistants who participated in this study.