http://orcid.org/0000-0002-5303-0209
Abstract
Background: There is extensive research on African girls sexual experiences, but much less is known about boys thoughts and actions. There is a need to understand the male perspective in order to develop sexuality education programmes that address the high rates of teenage pregnancy and sexually transmitted infections in sub-Saharan Africa.
Methods: For this qualitative, phenomenological study we spoke to 20 boys from Bolgatanga, Ghana and explored their sexual decision making, using semi-structured interviews designed to highlight psychosocial and environmental factors. Content analysis was used to construct categories and later the themes.
Results: Boys often had negative perceptions about sexual relationships. They believed that girls could not be trusted and mostly embarked on sexual relationships for material gain. The boys reported engaging in multiple sexual partnerships to secure their masculine status; however, they expected girls to be ‘faithful’. We found that accurate knowledge of safe sex was lacking, boys were under peer pressure to conform to beliefs about masculinity and communication about sex mainly took place within peer groups.
Conclusions: There is a need to emphasise condom use in established relationships. There should also be more discussion of issues surrounding fidelity and gender equality, as part of sexuality programmes aimed at boys in Ghana and in similar cultures.
Chinese abstract
背景：有关非洲女孩性经历的研究较为广泛, 但关于男孩的想法和行动却知之甚少。为了开展关注于撒哈拉以南非洲地区的少女高妊娠率及高性传播疾病的感染率的性教育计划, 有必要了解男性的态度。
方法：为了进行这种定性的现象学研究, 我们采访了来自加纳博尔加坦加的20个男孩, 并利用强调心理社会和环境因素的半结构化访谈来探索他们的性决策的制定。结论分析用于构建类别及以后的议题。
结果：男孩往往对性关系持负面看法。 他们认为, 女孩不可信任, 并且大部分都是为了获得物质利益而保持性关系。这些男孩称参与多个性伴侣关系以确保其男性地位; 然而, 他们期望女孩是“忠诚”的。我们发现男孩在同伴压力下遵守关于男性气质的信念, 关于性行为的交流主要发生在同伴群体中, 而他们对安全性行为的正确认识是缺乏的。
结论：在建立的关系中需要强调安全套的应用。 作为针对加纳男孩和类似文化的性教育计划的一部分, 还应该更多地讨论有关忠诚和性别平等的问题。
Introduction
Globally, an estimated 16 million births occur annually among young women aged 15–19 years [Citation1]. Most adolescent births (95%) take place in developing countries, 50% of which are in sub-Saharan Africa [Citation2,Citation3]. In Ghana, 30% of registered births in 2014 were by adolescent women (15–19 years) [Citation4]. Adolescent pregnancies are often unintended, are associated with higher maternal mortality and morbidity and are frequently terminated with an induced, mostly illegal, unsafe abortion [Citation5,Citation6]. Teen pregnancies also result in adverse social outcomes for the couple, including lower educational achievements than their peers, less likelihood of being employed and an increased likelihood of earning a low wage and living in perpetual poverty [Citation7].
With the correct and consistent use of condoms, with or without other contraceptive methods, adolescents can avoid pregnancy and the transmission of sexually transmitted infections (STIs). To promote contraceptive use among adolescents requires an understanding of the specific practices and beliefs that influence their sexual decision making. These factors may be similar or different for boys and girls. For example, while girls may not use family planning methods due to fertility concerns [Citation8], boys may consider getting girls pregnant as a mark of their masculinity and may therefore be somewhat ambivalent towards contraceptive use [Citation9,Citation10]. Also, while girls may engage in multiple sexual partnerships for economic reasons [Citation8], boys may behave in the same manner to promote masculinity and sexual prowess [Citation11].
In West Africa, adolescent boys play a crucial role in impeding or discouraging condom use in heterosexual relationships [Citation12] and can play an equally important role in promoting gender equality and safer sexual behaviours. In Ghana, Ampofo [Citation13] established that patriarchal attitudes prevail across age and sex, and in particular, girls are expected to abstain from sex until marriage, while boys exhibit high-risk behaviours including having multiple sexual partners and not using condoms to protect against pregnancy or STIs [Citation9–12]. Further support for factors influencing sexuality-related behaviours can be found in gender, masculinity and health behaviour-related theories [Citation14,Citation15].
In the present study, we spoke to 20 boys from Bolgatanga in Ghana, to explore their sexual decision making, using semi-structured interviews designed to highlight psychosocial and environmental factors.
Methods
Study design
The study used a qualitative phenomenological approach to explore boys sexual behaviours and contraceptive decision-making processes. The study was approved by the Ethics Committee of the Ghana Health Services, Accra and the Ethics Review Board of Psychology and Neuroscience at Maastricht University in the Netherlands.
Study setting
The study was conducted in the Bolgatanga Municipality, the capital of the Upper East Region, Ghana. The predominant tribal group in the municipality is the Frafra people, who are primarily engaged in agriculture-related activities and are among the poorest in the country [Citation16,Citation17]. The Frafra are organised along family and clan lines and polygamy is widespread. Extended families live in compounds next to each other.
Recruitment and participants
A purposeful homogeneous sampling technique [Citation18] was used to recruit participants. The study topic (i.e., adolescent pregnancy and strategies to reduce its occurrence in the Bolgatanga Municipality) was advertised on the walls of public buildings which young males were likely to visit by themselves and some via school teachers. The advertisement included information on the voluntary nature of the study, privacy of data collection, participation criteria (age 14–20 and residing within the Bolgatanga Municipality) and how to sign up.
Fourteen boys enrolled through public advertisements and seven through teachers. After interviewing 18 boys, saturation was achieved (i.e., additional interviews did not provide new information) and after another three interviews, recruitment was stopped. One participant was later found to be 23 years old and was excluded from the analysis, leaving 20 eligible participants ().
Table 1. Demographic characteristics and sexual experience of participant sample (n = 20).
Procedures
The location of the interview and its timing were determined by the participants. A young male Ghanaian research assistant and a young female Dutch undergraduate student, who conducted and transcribed the interviews, explained to the boys the informed consent process (i.e., their right to stop the interview at any time and the right to refuse to answer any question without having to give a reason) and assured the confidentiality of their information. Once he had fully understood, the participant was then asked to sign a consent form. Additional parental informed consent was sought for participants below age 18.
Interviews were conducted in English or the local language (Gurene) and lasted for approximately an hour. No compensation other than a soft drink was provided for participation but transportation costs were reimbursed. Research assistants recorded all interviews and transcribed them.
Research instrument
A semi-structured interview protocol was used that was based on cognitive theories and empirical findings explaining sexual behaviours within the African context [Citation19–22]. The guide was thematically structured to address topics such as relationships, sexual experience, pregnancy, gender, masculinity and communication about sex. The interview guide is available on request from the first author (JKK).
Content analysis
The first author read each transcript, checked it against the research assistant’s field notes, listened to the original interview recording to validate the transcripts and corrected any notable minor mistakes. Content analysis, using NVivo for Windows, version 11.0 (www.qsrinternational.com/nvivo/support-overview/downloads), enabled identification of the dilemmas, fears and beliefs expressed in the narratives and the construction of categories [Citation18,Citation23]. A three-level coding system was used [Citation24]. At level one, each transcript was read repeatedly to identify phrases that could be organised into general themes [Citation25], at level two (axial coding or pattern coding), the initial codes were grouped into smaller themes [Citation26]and at level three (selective coding), all codes were reviewed to confirm the various thematic categories. The second author (FEM) checked the three coding levels against the original transcripts and with the agreement of the first author, corrected some aspects of the coding. The thematic categories were then linked through logical deductions to achieve the highest degree of validation for the central summarised thematic areas reported below.
Results
Based on how themes emerged from the data, the results are presented as behavioural factors (girls and relationships, experience of condom use and responsibility for pregnancy prevention), environmental factors (communication about sex and experience of formal sexuality education) and psychosocial factors (knowledge about teenage pregnancy and contraception; attitudes towards safe sexual behaviours; teenage pregnancy and abortion; self-efficacy related to buying condoms; risk perceptions of pregnancy and STIs; perceived social norms towards teenage sexuality and pregnancy and intentions for condom use) of boys sexual and contraceptive decision-making processes. The boys talked a lot during the interviews, but it was not always clear whether they were simply excited to discuss sexuality issues or for some topics like sexual partners, exaggerated their experience as a way of raising their masculine social status. Pseudonyms are used to identify participants; additional relevant quotes can be found in .
Table 2. Overview of quotes and illustrating the results, organized based on the theme.
Behavioural factors
Girls and relationships
There was a general belief among the boys that ‘girls cannot be trusted’ to be faithful in a relationship because they only look for money and therefore engage in multiple relationships. They said, because girls cannot be trusted, boys also engage in multiple sexual relationships, besides their ‘main’ girlfriend, as a relationship security:
‘Because nowadays the girls are no more trusted, so maybe if I have one girlfriend then she changed her mind because girls are easily convinced. Maybe someone comes to convince her and she changes her mind, it will be very hard for me. However, if I have about two or three girlfriends, then even if she even breaks up, it will be normal’. (Adams, age 19)
The boys said they frequently broke up relationships with girls because of the same issue of trust and perceived unfaithfulness. The boys reported that, among peers, not having a girlfriend was not acceptable. Thus, having or reporting to have multiple girlfriends was partly related to the status of being a boy. In most cases, the boys hid their relationships with other girls from their ‘serious’ girlfriend because they thought if she knew he had multiple partners it would ruin the relationship. At the same time, they would break up with their girlfriend if they discovered she was dating other boys.
The boys believed that girls accepted their friendship because they hoped to get money or other material gifts from them. Consequently, boys often invested material resources in maintaining a relationship.
Some boys reported positive boy-girl friendship experiences, but such experiences were atypical. Some also believed that boys were expected to help encourage girls because God created boys to be superior to girls. Frequently, they described girls as not equal to boys, being quite emotional or having a ‘small brain’:
‘Anyway, I think the lady, or should I say, girl, the brain system of a girl […] is very small. I see it as very small because it can be manipulated at any time-at any point in time. Girls are very much emotional, so anything you tell them can influence the steps they will take the following day’. (Agana, age 19)
The boys exhibited a superior masculine attitude towards girls. Partly because if they had spent money on a girl, they expected her to obey their request to have sex or risk a break-up of the relationship.
Experience of condom use
Among the sexually active boys, only a few reported consistent condom use, mostly to protect against STIs rather than to prevent pregnancy. The reasons for not using protection included not wanting to use condoms because it reduced sensation and affected libido and lack of preparation (not having condoms available). Other reasons were using the so-called ‘safe period’ of a girl’s menstrual cycle, not having money for condoms, using the withdrawal technique or because they trusted the girl and felt no need to use condoms:
‘Sometimes I do not use condoms […] it depends on who I am going to have sex with. Some girl, if I trust her, I do not use a condom’. (Adongo, age 20)
Responsibility for pregnancy prevention
Most boys believed that it was their duty to have condoms available and to protect against impregnating girls. This was partly because they felt it was their responsibility if a girl became pregnant:
‘Because you are the one who releases the sperms into her and the sperms form a child, so you are the one because a girl cannot’. [laughs] (Azuma, age 18)
Others acknowledged that it was harder for girls to buy condoms because of the general expectation that girls should abstain from sex until marriage and without condoms a girl may refuse sex. A few said that both partners were responsible for condom use, but they still preferred to carry a condom to be in control of or ‘master’, the situation.
Environmental factors
Communication about sex
It was evident from the interviews that communication about relationships and sex among boys occurred mostly when they were together with their peers. When asked what they talked about, it was common to hear:
‘By all means, you like to friend a girl, so when we gather, we talked. This boy will bring his idea […] after that we are now going to tell you what to do’ . (Azuma, age 18)
Part of the sex communication with peers seemed to be about putting pressure on those who did not have girlfriends or were not yet sexually active to get into a relationship as a way of fulfilling peer group norms. For most of the time, peer talk included joking about girls and sex or boasting about sexual experiences. Some said they had serious talks about sex-related issues, such as warning each other of potential risks.
Regarding general life issues, boys reported open communication with at least one of their parents. But, regarding sexuality, they mostly received moral instructions from their parents such as staying away from girls and abstaining from sex to avoid pregnancy and disease or for religious reasons. Most felt uncomfortable discussing sex with their parents, partly because of the fear of being regarded as precocious. Only a few boys mentioned talking to a teacher, girl or girlfriend about sex-related issues.
Experience of formal sexuality education
Most of the boys indicated that they had received sexuality education at school, e.g., during science lessons or by non-governmental organisations staff or peer educators. However, when asked, the exact content often remained vague or very diverse. It seemed limited to basic information and warnings about the need to protect against impregnating girls or contracting STIs. Some of the information they had received also seemed incorrect: advice to use ‘withdrawal’ was, for example, mentioned as a safe sex technique learned at school. Only a few explicitly stated they received training in how to use a condom:
‘Yeah […] I never knew about contraceptives, so it was just in class that I got to know about contraceptives, how to use the pill, withdrawal and condoms’. (Ayeebo, age 18)
Psychosocial factors
Knowledge about teenage pregnancy and contraception
In general, the boys talked a lot about the risk and consequences of impregnating a girl or contracting STIs if they engaged in unprotected sex. They were fairly aware of the negative consequences of teenage pregnancy, especially how it affects their partner’s education and her life in general. However, only a few seemed to really understand how to correctly prevent pregnancies. The withdrawal method and the girl’s ‘safe period of the month’ were still mentioned as safe sex techniques. Their knowledge of contraception was frequently limited to condoms:
‘Apart from condoms, I don't know about the rest’. (Atinga, age 20)
They were aware that girls could use other contraceptives, but none could be specific beyond the emergency contraceptive pill or the female condom. Mostly, they referred to hormonal contraceptives as ‘some drugs’ or ‘other family planning methods’ that girls could use to avoid pregnancy or spoke of the possibility to ‘urinate out the sperms after sex’.
Attitudes towards safe sexual behaviours, teenage pregnancy and abortion
The boys attitudes towards teenage sex often contradicted their experience and behaviours. They stated that it is ‘not good to have sex’ and the teenage years should be ‘invested in education and not sex’. At the same time, most admitted having had an early sexual debut:
‘At that age, you know, you‘ve got to concentrate on studies. Even though I started having sex at this age, I see it as bad’. (Amidu, age 17)
It appeared that negative beliefs about teenage sex were an extension of parental, school or religious advice and not the actual attitude of the boys.
The boys also had negative attitudes towards teenage pregnancy, expressing that ‘teenage pregnancy is very bad’. They believed it was not suitable for either young partner and society also did not accept it. About half were of the view that abortion was the inevitable choice for them should they mistakenly impregnate a girl. The others thought that abortion was evil and constituted a kind of ‘killing’ and would prefer the girl to give birth rather than abort. Their religious beliefs influenced their attitude towards abortion:
‘Actually, in my religion it is a dangerous thing to do […]. It means that you are killing a human being’. (Agana, age 19)
Regarding condoms, their attitude was divided. Some indicated that condoms were necessary to prevent STIs, while others reported bad experiences with condoms, such as friction resulting in pain to the girl, bruises or preventing their penis from staying erect. These participants preferred to ‘go raw’ or ‘flesh to flesh’ or said it was their girlfriends who requested ‘raw’ sex.
Self-efficacy related to buying condoms
The boys said they had felt shy buying condoms when they were much younger, but in their later adolescent years they had no problems buying condoms at a pharmacy. One boy explained why they found it easy to purchase condoms from a pharmacy:
‘You know when condoms came, adult men were feeling shy to go and buy them. They always sent small, small boys to buy condoms. By doing that, they made us (boys) get used to buying condoms. So now, if I go to buy condoms, the store’s attendant will be thinking that I am just buying it to give it to somebody else’. (Akutam, age 19)
Risk perceptions of pregnancy and STIs
It was common to hear the phrase ‘when I trust a girl, I don’t use protection’ in the interviews. This judgement of ‘trust’ (i.e., perceiving whether a girl had an STI or not) seemed based on superficial characteristics such as her appearance and friends:
‘You look at a girl then you can tell, just like the saying “show me your friend and I’ll tell you your character”. You see the girl, the friends that she is with, you can tell. And the way that she dresses, you can tell the kind of girl she is.’ (Ndeogo age 18)
Most boys thought that most girls had sex with different guys, were carriers of STIs and could not be trusted, which made condom use important. The boys worry seemed mostly directed to their becoming infected rather than towards the girl becoming infected or pregnant. They stated that if they did not have bruises or sores on their penis, then they felt they were safe and could have unprotected sex.
Perceived social norms towards teenage sexuality and pregnancy
The boys indicated that their parents, religious leaders and community members expected them to abstain from sex until marriage. They therefore dreaded the risk of impregnating a girl and suffering social scorn. They admitted that it was difficult to adhere to the social expectation of not having sex, especially when peers told them of their experiences dating girls:
‘Most churches, they preach or they teach against immorality. They say sex is immoral, maybe unless you are married […]. But so far, you’re also a guy, and then most of your friends are dating, so you also have to carry yourself in those shoes’. (Alale, age 18)
Some believed that boys came under pressure to date girls, have sex or engage in multiple sexual relationships because their peers expected them to do so to enhance their social status.
Intentions for condom use
Most of the boys had clear intentions to use condoms to protect against both STIs and unwanted pregnancy. Most also said they would use condoms if girls insisted and made condom use a condition for sex:
Interviewer: ‘What kind of girl would make you use a condom?’.
Participant: [laughs] ‘Maybe if I have tried sometimes to have the girl and the girl doesn’t give in, then the only option for me is to use a condom’. (Ayeebo, age 18)
However, ‘in the heat of the moment’, if they trusted a girl and if they did not have bruises on their penis they might not use a condom.
Discussion
Principal findings
In this study, we spoke to 20 boys from Ghana to explore their sexual decision making. We found that the boys struggled with many conflicting norms, beliefs and attitudes. They held negative perceptions about (sexual) relationships with girls, feeling that girls could not be trusted to be faithful and were mostly interested in material gains rather than the need for intimacy. However, the fear of losing a girlfriend, together with masculinity beliefs that men needed girlfriends, made boys engage in multiple sexual relationships to fulfil peer norms. Although the boys felt very responsible for condom use and were very confident in buying them, they frequently engaged in unprotected sex, citing reasons such as feeling safe with girls who could be ‘trusted’, believing that the girl was in her ‘safe period of the month’ or having difficulties using condoms. The community’s norm of abstinence until marriage caused negative attitudes towards their teenage sexuality and seemed the main worry behind impregnating a girl. The boys hardly talked about sexuality topics at home and had limited sexuality education at school, but communicated frequently about sex among their peers. Their knowledge of contraception was limited to condoms, the withdrawal technique and a girl’s safe period of the month.
Strengths and weaknesses of the study
One of the biggest strengths of this article is its focus on boys perspectives. There is a great lack of studies of boys reflections on (sexual) relationships and teenage pregnancy. The data are very relevant for developing comprehensive sexuality education tailored to the needs of boys. Also, following Guba and Lincoln’s trustworthiness criterion for rigour in qualitative research [Citation27], various strategies including purposeful sampling, use of field notes, audio recording, transcript auditing and investigator triangulation were deployed in this work [Citation28].
However, despite these rigorous measures, we acknowledge some study limitations. Since this is a report of qualitative interviews of boys from rural Ghana, the findings may not be applicable to other settings or dissimilar cultures. Our sample included boys without experience of sexual intercourse. Their responses to how they would handle actual situations in sexual relationships are therefore hypothetical. Also, the interviews were conducted by two young people (male and female). It is unclear whether the participants provided answers that were meant to sound impressive or socially acceptable to the female interviewer. Furthermore, the fact that both interviewers were themselves young meant that they had limited experience in conducting qualitative interviews. Perhaps more experienced researchers would have detected socially acceptable responses and probed further for clarity. On the other hand, the fact that the interviewers were relatively close in age to the participants might have contributed to more open responses.
Differences in results in relation to other studies
Our participants reported engaging in multiple sexual partnerships to ensure that even if some of their partners left the relationship others would still be there to fulfil their needs. Such expectations of appropriate male sexual behaviours encouraged boys to assume a form of patriarchal ownership of girls. In this way, hegemonic masculinity inevitably links having multiple sexual partners with the subordination of girls to boys control [Citation11]. For example, while our participants engaged in multiple sexual partners, they were quick to condemn girls who had more than one boyfriend. Such retrogressive gender notions by boys increase their risk of making girls pregnant or leaving them vulnerable to STIs [Citation29], as the male partner mostly controls sexual activity, thus constraining girls ability to practise safe sex.
We found links between condom use, relationship type, fidelity and trust of the sexual partner. Participants were aware of the protective value of condoms for both STI and pregnancy prevention. However, trust and condom use were often discussed as mutually exclusive. Among study participants, a decision on whether to use a condom was based on the amount of trust in a girl, which in turn was judged according to physical appearance or diffidence in social relations and sexual fidelity. Previous studies on heterosexual relationships have also shown that, just like girls, boys consider ‘trust’ and ‘love’ as central in defining the meaning of sexual involvements and contraceptive use [Citation30–32]. What is interesting about this study is the contrast between the boys demand for relationship fidelity from their ‘main’ girlfriends and the reality of keeping several ‘spare’ girlfriends. This contrast makes condom use necessary even in ‘faithful’ relationships, yet unlikely. The boys are looking for girls who can be trusted in a monogamous relationship, but their behaviours reflect the opposite.
Also, the boys narratives show an absence of love and intimacy in the constructions of sexual relationships and safe sexual behaviours. Previous research linked young heterosexual men’s non-use of condoms to a desire to cultivate a loving and meaningful relationship at all costs, including risk to their health [Citation31,Citation32]. However, trust rather than love was the central theme of the boys narratives in this study. The finding shows that understanding heterosexual boys (un)safe sexual behaviours requires considerable knowledge of how relationships are constructed and given meanings. When the boys had unsafe sex with their ‘spare’ or ‘main’ partners, they interpreted it in a manner which has only been partially explored in the existing literature in West Africa. Given the small number of participants, it cannot be claimed that the observed patterns would be the same for all heterosexual boys in Ghana or in similar cultures. However, the possibility that these configurations of meaning and gender notions are present in similar forms in the lives of other boys deserves further research. There is also the need for interventions to address precisely issues of trust and emphasise that STI testing within ‘faithful’ relationships may not be comfortable but is necessary.
The findings further point to the need for programmes aiming at promoting condom use among boys to address self-efficacy to use condoms in difficult situations, including safe sexual communication and negotiation skills [Citation33]. Equally necessary is the need to emphasise the importance of having condoms available and carrying them when going out to social functions, so as to ‘be ready’. Also, since young people frequently cite the cost of condoms as one of the most common barriers to their use [Citation34], initiatives such as placing free condoms in public lavatories should be encouraged in order to improve access, especially in poorer populations.
The beliefs of our study participants confirmed those reported in previous studies of adolescent African girls, which have shown that social norms and economic motivation encourage teenage girls to be sexually active before marriage and to engage in multiple sexual partnerships [Citation8,Citation35,Citation36]. In particular, economic motivation can cause girls to engage in intergenerational sex, increasing their risk of both STIs and unintended pregnancy [Citation36]. Also, with deteriorating economic conditions in most African countries, the use of premarital multiple sexual relationships as a means of economic survival is more likely to increase. Under such environmental conditions, the promotion of contraception (including condom use) for pregnancy prevention is more likely to achieve the desired outcomes than programmes aimed at reducing the number of sexual partners, because for adolescent girls that would bring about their social and economic demise. Also, the finding highlights the need for interventions aimed at promoting safer sexual practices among girls to incorporate economic empowerment and gender equality components [Citation37].
Our participants reported having to deal with two conflicting norms: the cultural norm of abstinence before marriage and the peer norm to have sex and girlfriends. It seems our participants were more likely to give in to the peer norm, which could be the reason why most of them experienced early sexual debut. Several studies have reported that boys frequently experience pressure to prove their masculinity by engaging in sexual relationships [Citation38,Citation39]. In South Africa, Selikow et al. [Citation40] found that if boys were perceived as not being sexually active they risked being excluded from their peer group. Blum’s review [Citation41] of trends and outcomes related to young people’s sexual and reproductive health across sub-Saharan Africa reported that both girls and boys do experience significant peer pressure to be sexually active. Susceptibility to peer pressure differs among young people, but adolescent boys appear to be more susceptible compared with teenage girls [Citation42]. However, peer pressure is not necessarily a negative influence. Positive examples set by friends and role models can promote safer sexual behaviours and have been cited as the basis for youth peer sexuality education programmes [Citation43]. Thus, it is important to ensure that all adolescents have access to the right role models and correct sexuality information so that their influence over each other can be in a positive direction. This is particularly so because, among boys, sex communication largely occur within peer groups.
Implications for clinicians and policy-makers
In our study we have found a critical need to decouple condom use and infidelity in the minds of young people. Especially, for adolescents who want to prevent pregnancy, more messages on dual protection (using condoms in addition to other safe sexual practices) could help destigmatise condom use within faithful relationships. Also, adolescents need to understand that ‘being faithful’ only protects them from STIs if they are faithful to one mutually monogamous, non-infected partner and that being faithful still requires attention to pregnancy prevention. The double standard of boys expecting fidelity from their main girlfriends but keeping secret spare girlfriends means adolescents in ‘faithful’ relationships will always need to assess their risk of STIs and consider condom use and repeat STI testing within relationships. Also, these findings suggest the need to give particular attention to the matter of trust and fidelity in intervention planning. To promote consistent condom use among boys, it should be projected as a positive, progressive and healthy quality of ‘cool’ masculinity, along with the promotion of gender equality and male participation in sexual and reproductive health decision making. Finally, it is important to expand access to comprehensive sexuality education for all young people. When they are all well equipped with the correct information and skills, their influence on their peers is likely to be positive towards safer sexual behaviours [Citation44,Citation45].
Unanswered questions and future research
Future efforts to investigate some of the complexities and contradictions that are inherent in adolescent boys heterosexual relationships are warranted. Such efforts may also specifically examine the social construction of types of partners and how sexual behaviours vary according to partner type. Reports on these topics will provide valuable information to inform the development of effective programmes that addresses the cultural norms and particular needs of boys.
Conclusions
Interventions aimed at promoting safe sexual behaviours among boys in Ghana or in similar cultures may have a higher chance of succeeding if they place emphasis on condom use, also within ‘faithful’ relationships and include specific components addressing issues related to trust, fidelity and gender equality.
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