Sexual knowledge based on Islamic values and sexual risk behaviors of HIV/STIs among Thai Muslim army conscripts: A cross-sectional study

Background

Separatist violence in Thailand’s Muslim-majority southern provinces, Yala, Pattani, and Narathiwat, has been ongoing since January 2004 (Crisis Group Asia Report, 2012; Hinojar, 2012). This region lies between Buddhist Thailand and the Malay Muslim states of northern Malaysia (Pathan, 2012). From January 2004 to October 2021, 7,294 died, and more than 13,550 were injured due to the violence (Deep South Watch, 2021; Jitpiromsri et al., 2018). A recent report indicates that as of January 2020, there were 7,085 dead and more than 13,233 people injured in total (Deep South Watch, 2020). Security personnel have been deployed to the area to support a peace settlement. Among the security forces are army conscripts deployed to ensure security (Pathan, 2012) and reduce violence (Crisis Group Asia Report, 2012).

Sexually transmitted infections (STIs) are commonly found in conflict situations (Korzeniewski et al., 2020), and high-intensity border and domestic conflict can damage sexual health (Chuemchit et al., 2018). In World War I and II, gonorrhea was the most common STI that removed soldiers from duty. Likewise, STIs were also prevalent in the military environment of the Korean War, Vietnam War, and United Nations peacekeeping operations. STIs have often been higher in conflict areas than in peaceful ones (Korzeniewski et al., 2020).

HIV is an STI that can lead to acquired immune deficiency syndrome (AIDS), which impairs or damages the immune system (Kapila et al., 2016). Young and sexually active army conscripts have a considerably high risk of STIs (Surit et al., 2017). From 2005 - 2011, HIV among Thai army conscripts was approximately 0.5% (Sakboonyarat et al., 2021). The Thailand government has set a goal of ending the AIDS epidemic in the country by the year 2030 (Muccini et al., 2019), but a 2018 survey of 36 military units found that the prevalence of HIV in new army conscripts had doubled compared to the previous study in 2011 (Sakboonyarat et al., 2021). The prevalence of HIV among men who have sex with men (MSM) in the general population had increased from 19.2% in 2005 - 2006 to 34.0% in 2010, remaining stable until 2016 and then reaching approximately 17.2% in 2018 (Pattanasin et al., 2020). In a military environment, HIV/STIs should be a concern not only for male conscripts and their female sex partners but also between male conscripts and other males (Korzeniewski et al., 2020; Surit et al., 2017).

A study conducted during this violence crisis showed a high prevalence of HIV/STIs among military personnel. However, despite the importance of religious belief for sexual health, lack of studies on this topic in Thailand (Hayee et al., 2021). The three southernmost provinces of Thailand are Muslim majority areas. People respect and strengthen their belief in Islam. Therefore, it is hypothesized that people with more strengthening practices in Islam have lower sexual health risk behavior. This study investigated the association between participants’ sociodemographic characteristics, religious-based sexual knowledge, and risk of HIV/STIs among Muslim army conscripts. Preventing HIV/STIs, nursing practice in sexual health promotion concerning norms, beliefs, cultural background, and religion is needed (Åling et al., 2021). The study findings could support the development and implementation of nursing practice in health promotion by conducting religious-based programs to reduce sexual risk behaviors among army recruits in Thailand and civil Muslims.

Methods

Results

A total of 421 completed questionnaires were returned and included in the data analysis. Table 1 shows that most participants were 22 years old or younger (74.3%) with a secondary school education (65.1%) and single marital status (79.8%). The birthplaces were relatively evenly split between the three southernmost provinces and all other provinces (52.7% and 47.3%, respectively). Respondents were deployed in Yala, Pattani, and Narathiwat provinces at proportions of 37.3%, 34.9%, and 27.8%, respectively. Half were active smokers (50.4%), more than a third were active consumers of alcohol (37.5%), and a small minority were substance users (2.4%).

Table 2 presents the participants’ sexual knowledge relevant to Islamic aspects. Most participants correctly reported that Islam granted permission for vaginal sexual intercourse among married couples (78.1%) and that caressing without insertion was also allowable (61.0%). However, most did not correctly identify that Islam disapproves of the withdrawal technique between married couples in sexual intercourse (37.1%) or the use of a condom used for oral sexual intercourse in married couples (36.8%). Most were correct in answering that having sexual intercourse with another female apart from one’s own wife (65.6%) and using the withdrawal technique in sexual intercourse with others (60.1%) were forbidden. Most did not correctly respond to an item regarding whether to have oral sexual intercourse among married couples (disapproved) and to use condoms when either side of the married couple had an STI (forbidden) (24.5%). The items that were most commonly answered correctly regarded having vaginal sexual intercourse in a married couple, having sexual intercourse with women other than one’s own wife (65.6%), and just hugging and caressing without insertion in a married couple (61.0%).

In addition, Table 2 shows the sexual knowledge level based on Islamic aspects among Muslim army conscripts deploying in the conflict area of the three southernmost provinces of Thailand. The results indicated that 57.5% had a poor level of sexual knowledge, 28% had a moderate level of sexual knowledge, and only 14.5% had a good level of sexual knowledge according to Islamic aspects.

Table 3 presents the risk for HIV/STIs categorized by participants’ behaviors. Among the 421 subjects, 61 subjects (14.5%) never had sexual intercourse in their lifetime. These were classified as low risk. However, inconsistent condom use in married and single respondents, reported by 29.7%, was classified as high-risk behavior.

Table 4 shows the association between subject characteristics and risk for HIV/STIs using Chi-square. The results found that participants’ marital status, home base provinces, smoking and drinking status, and Islamic values-based sexual knowledge were potential factors significantly associated with their risky behavior of HIV/STIs (p <0.05). According to the results, we can observe that the strongest associated factors with a high risk of sexual behavior related to HIV/STIs were poor sexual knowledge according to Islamic aspects, followed by marital status, cigarette smoking, alcoholic drinking, and the subjects’ home base.

Discussion

Our study found that sexual knowledge according to Islamic aspects was associated with risk for HIV/STIs. Poor knowledge clearly increases the risk for HIV/STIs among the Muslim army conscript. This finding is similar to studies showing that individual factors related to knowledge of sexual behavior in Islamic doctrines could increase the rate of condom use to lower the risk for HIV/STIs (Haddad et al., 2018). Our study also found that active smokers had a high risk for HIV/STIs, which is consistent with the previous study of male youths in Malaysia (Farid et al., 2014). This may be because active smokers are more likely to use alcohol and drug, which could lead to unprotected sexual intercourse (Dickson-Gomez et al., 2017; Myers et al., 2007; Yu et al., 2013). Smoking is harmful and prohibited by Islam, which calls upon worshippers to look after their health (World Health Organization, 2000). To lower smoking rates, such as through an antismoking campaign, awareness of religious beliefs should be exploited (Ghouri et al., 2006).

Those with sexual abstinence and participants with good sexual knowledge had a lower rate of HIV/STIs prevalence rate. These may have been practicing Muslim functioning under religious constraints that lead to a lower risk for and prevalence of HIV/STIs (Gray, 2004; Piriyasart et al., 2020).

Although most participants had finished secondary school (65.1%), the majority had a low level of sexual knowledge based on Islamic aspects, which is inconsistent with a study in Malaysia that found a high level of sexual knowledge in similar circumstances (Barmania & Aljunid, 2016). This may be because most of our participants attended general school, not Islamic school. In public school, only general sexual knowledge is provided, while Islamic school focuses more on Islamic aspects of sexual knowledge, which benefits students (Alomair et al., 2020a, 2020b). On the other hand, STIs could be prevented if the traditional norms (Haberland, 2015) and rules of Islam were applied to Muslims (Hamdi, 2018).

The questionnaire results indicated a variation in sexual knowledge based on Islamic principles. Oral sexual intercourse in married couples is controversial in parts of Thailand and other countries (Dotson-Blake et al., 2012; Halstead, 1997; Kerwin et al., 2014). However, most participants (62.1%) considered engaging in oral sexual intercourse acceptable. In addition, this group featured oral sexual intercourse with their friends and sexual partners, which was significantly associated with an increase in the number of sexual partners (Dotson-Blake et al., 2012) and consequently with premarital sexual intercourse (Kerwin et al., 2014) including lifting the risk of HIV/STIs.

Surprisingly, in face-to-face interviews, a misconception of Islamic rules regarding oral sexual intercourse, condom use, and withdrawal methods with other sexual partners apart from the wife was not considered sex outside marriage. Some participants asserted that sperm did not pass into the vagina in the withdrawal method. This incorrect belief could lead these participants to have a high risk for HIV/STIs because they will have sexual intercourse more frequently and have larger numbers of sexual partners. Such attitudes should receive immediate modification and adjustment.

Sex outside of marriage should be clarified among these participants. Misperceptions and misunderstandings should be eliminated (Najimudeen, 2020). A suitable cultural program for sexual behavior improvement should be provided (Abdi et al., 2021) because Islam is a highly practical religion, and Muslims are influenced by Muslim scholars and religious leaders (Abdi et al., 2021; Barmania & Aljunid, 2016; Hamdi, 2018). Appropriate and correct behaviors should be presented to allow these recruits to practice Islam according to the Quran.

More single Muslim army conscripts (76.4%) had had premarital sexual intercourse than seen in a report in the United States, indicating that 53.8% of unmarried Muslim youths had had sexual intercourse (Ahmed et al., 2014). In addition, more than a fifth of married participants in this study reported sexual intercourse outside marriage (22.3%), which is contrary to Islamic rules (Alomair et al., 2020b; Hamdi, 2018; Inhorn, 2007). These behaviors bring a high risk for HIV/STIs. This finding could be brought to bear to shape the viewpoints of Muslim males restrained by politics, culture, and religious beliefs (Abdi et al., 2021). In addition, all Muslims who follow religious practices regarding forbidden sexual behavior could protect themselves from HIV/STIs (Alomair et al., 2020a, 2020b).

Human beings can learn to control their sexual drives and desires to develop ethical practices because sexual relations are considered holy behaviors with legal sexual partners through relationships through lawful Islam (Assad et al., 2016; Hamdi, 2018). The best way to avoid STIs is to practice abstinence (Wannarit, 2022), followed by masturbation. Masturbation is considered a sin and forbidden in Islam (Assad et al., 2016; Inhorn, 2007). However, views differ on different religious beliefs in other parts of Thailand and other countries (Albobali & Madi, 2021; Inhorn, 2007). However, those who have sexual intercourse outside marriage, which goes against Islamic rules, should have a more social responsibility to protect themselves and others from contagious diseases (Singkun, 2021). In addition, these participants should be encouraged to increase their condom use (Cumber & Tsoka-Gwegweni, 2016), although this practice is controversial (Najimudeen, 2020; Speed & Cragun, 2021).

The participants’ responses indicate that one-third had a high risk for HIV/STIs. Sexual and reproductive health is a sensitive issue (Najimudeen, 2020). However, Islamic rules should be used to teach Muslims appropriate sexual behavior (Hamdi, 2018; Hayee et al., 2021). In addition, the strongest religiosity has a significant inhibiting effect on risky sexual behavior (Ahmed et al., 2014; Dotson-Blake et al., 2012).

Although this study found several factors associated with HIV/STIs risk, some limitations must be addressed. First, the questionnaire identified education levels that asked only about the participants’ general education, omitting any Islamic education. This may lead to the misclassification of Islamic knowledge related to sexual behavior. Second, the recruitment of participants in this study was conducted at security checkpoints that were clustered in city centers. This may affect the generalizability of the results to remote outer areas. However, the magnitude of sexual risk behavior could more easily be observed in the city area than in the remote outer regions.

Conclusion

The study explored knowledge of Islamic precepts on sexuality among Muslim army conscripts deploying in the conflict area of the three southernmost provinces of Thailand. Most subjects had a poor level of knowledge according to Islamic principles. One-third of reported sexual behaviors related to high risk for HIV/STIs. Smoking and Islamic values-based sexual knowledge were associated with increased risk behavior for HIV/STIs. The strongest association predictive variable was knowledge of Islamic doctrines on sexual behaviors. This study provides crucial knowledge for health promotion in public health and nursing practice in a strongly religious belief community.

Further study related to sexual health education is encouraged to strengthen the sexual knowledge based on Islamic principles among Muslim army conscripts in the southernmost provinces of Thailand. Sexual health education in specific Muslim majority areas should be created and implemented with the collaboration of healthcare providers and leaders of religious communities. The roles of nurses and public health professionals are necessary in sexual health promotion to achieve the level of expected knowledge and sustainability in order to lower the risky behavior for HIV/STIs in the population at large.