Why do male students in higher education buy sex? A Phenomenological Exploration

Epidemiological and behavioral studies have concentrated on female sex workers. There's a crucial ought to focus equivalent attention on the activities of male clients as has been directed towards female sex workers. In Ethiopia, where higher education students considered as the most at-risk population for human immune deciency virus, the transmission of infection may occur within networks composed of female sexworkers, their clients and the other sexual partners of the latter. However, there is a huge gap in qualitative studieson the exploration of why higher education male students buy sex. The purpose of this study was to explore why higher education male students buy sex.


Objective
The purpose of this study was to explore why higher education male students buy sex.

Methods
A qualitative phenomenological approach was used. Semi-structured interviews wereconducted with 12 higher education male students who had a history of visiting female sex workers during their stay on campus.Inductive codingwas used to determine invariant constituents reduce constituents to sub-themes, and clustersub-themes into themes. Dependability and credibility were achieved through an audio recording, bracketing, and member checking.

Results
Through the use of thematic analysis two common themes and ve sub-themes were identi ed from motives of male higher education students to buy sex.These themes are motives associated with desires including emotional and experiential; and motives associated with context including academic, time and money context, socio-environmental context and family, romantic partner and campus girl context.

Conclusions
In this study, Sexual need, sexual fantasies,experiential desire, Peer pressure, substance use, low academic result, availability of time and money, break up with a romantic partner and demanding nature of campus girls were the reasons reported by participants when they were asked about why they visited female sex worker. Therefore, addressing higher education male students' motives related to their desire and context is vital.
Background Page 3/12 Key populations are de ned groups who, due to speci c higher-risk behaviors, are at increased risk of Human immune de ciency virus irrespective of the epidemic type or local context. Also, they often have legal and social issues related to their behaviors that increase their vulnerability to HIV, Hepatitis B and C, and syphilis [1].

Studies conducted in African countries found that the HIV prevalence among FSWs varied between 19%
and 60% [2][3][4][5].Available limited evidence indicates that HBV and HCV infections are endemic in Ethiopia where HIV and syphilis are also prevalent [6,7]. In Ethiopia, higher education students have been identi ed as one of the highest-risk populationsfor HIV and other Sexual transmitted infections [8].
The belief that FSWs might play a key role in the heterosexual transmission ofHIVand other STIs infections has led to attention being focused on the activities of women who sell sex. Therefore, epidemiological and behavioral studies have concentrated on such topics [9,10,11]. However, by focusing so much attention on the activities of the female sex worker,as opposed to the activities of men who buy sex, an impression is created that such women are the sole contributors to commercial sexual exchanges when, in fact, they compromise only one-half of those exchanges. Though, there is an important need to focus equivalent attentionon the activities of male clients as has been directed towards FSWs [10,12,13]. Gaining depth understanding of why do male students in higher education buy sexis very helpful for public health professionals to design the appropriate health promotion and prevention strategies.
Therefore, as far as the researcher knowledge this study is the rst in Ethiopia which viewing commercial sex from female sex worker's clients' side and tries to nd out why do male students in higher education buy sex.Through this paper, the researchers contribute to the future direction of the contemporary public health system in Ethiopia.Furthermore, the researcher ambitious to be the rst in the introduction of a new concept that is called "male reproductive health".

Study design
A qualitative phenomenological approach was used in this study.
Sampling and participants A sample of 12 higher education male students participated in this study based on information saturation. Snowball sampling was used to identify higher education male students who have experienced the phenomenon of buying sex. The participants were recruited from all higher education institutions in Dessie City, Ethiopia. This exploration was approved by the Internal Review Board of the School of public health, Addis Ababa University.After a detail explanation of the purpose of the study and how it safeguards the privacy of participants, verbal and written consent was obtained from each study participants. Participants who were refused to participate in the study were not being forced and participantscan withdraw from the study at any time.

Data collection
The principal investigator was collected the data.A semi-structured interview protocol was developed by the principal investigator, reviewed by the experts, and edited based on feedback. Semi-structured interviews were used to obtain the datato document the participants' reasons to buy sex. The interviews were audio-recorded and were transcribed within the actual words of the participants (to maintain the integrity of the data). The participants' were told concerning the aim of the interview, and time was put aside at the top of the interview for re ection on the method of the interview.
The interview protocol enclosed ve main queries regarding why educational activity male students obtain sex. Throughout the course of the interviews, probes and follow-up queries were added as required to encourage rationalization and clarify replies. Detailed questions were added as the interview process steps forward in response to rising themes.

Data analysis
Thematic analysis which helps for recognize, investigate and report patterns (themes) within data was used to develop the themes. The following steps were followed to analyze the data as recommended by Braun and Clarke (2006):(a)familiarization with the data, (b) generation of tentative codes, (c) elucidation of themes, (d) review of themes, (e) delineationof themes and (f) production of the written report. These steps were repeated several times to further group and reduce categories.

Dependability and Credibility
Field notes, an audio record, inter coder agreement, bracketing, member checking were used to assure dependability and credibility of this study ndings and interpretations. Final themes, as well as subthemes, were shared with allparticipants for review. Participants were asked toexamine these themes and re ect on the accuracy and reported that the identi ed themes and subthemesaccurately re ected their motives.

Socio-demographic and related pro le of participants
The average age of the higher education male students interviewed during this study was twenty three years with vary being from twenty one to twenty six years. Exactly half of the respondents, 6 out of 12 were followers of orthodox Christianity, 3 were Muslim and 3 were Protestants. Three of this study participants said that they had not used a condom on the last occasion of having paid for sex. The majority (10) of this study participants reported having paid for sex for the rst time when there were rstyear students (See table 1). Theme: Motives of male higher education students to buy sex Through the use of thematic analysis two common themes and ve sub-themes were identi ed from motives of malehigher education students to buy sex.These themes are motives associated with desires including emotional and experiential desire, and motives associated with context including academic, timeandmoney; Socio-environmental, and family,romantic partner/ Campus girl context. Findings throughout this paper use pseudonyms to maintain con dentialities of study subjects.
Theme1: Motives associated with desires The participants described motives associated with desiresthat impacted on involvement in visiting female sex workers. Two sub-themes emerged fromparticipants' motives associated with desiresthat impacted higher education male students' involvement in visiting FSWs in this study, including emotional and experiential. Sub-theme2: Experiential desire For some males in higher education the principal motive of visiting FSWs seemed to lie in the potential to try and learn new things. Amongst those males who drew explicit attention to the appeal of sex with for experiential purposes would sometimes be made to lifestyles that had been enjoyed before they were married or when they were younger. Sex with FSWs was regarded as one way in which it was possible to experience again such behavior:[Abel, 2 nd -year natural science student, aged 19]the youngest participant of this study said "…They talked a lot about female sex workers, the night clubs, the dancing with girls and other many things so I took the positive side of their talk and it seemed to be a new thing to try…" Notably, none of these study participants cited any form of love and affection with FSWs as a reason for buy sex, except Yechelale who reported "…She [sex worker] tell me her touching story; I care for her, She cares for me, besides, to share our sexual feelings…".

Discussion
This study explored why higher education males students buy sex in the context of phenomenology, providing an in-depth understanding of higher education male students' motives to visit female sex workers.
Through the utilization of thematic analysis 2 common themes and 5 sub-themes were known from motives of male higher education students to buy for sex. These themes are motives associated with desires including emotionaland experiential desire and motives associated with context including academic, time and money context; Socio-environmental context and family, romantic partner/ campus girl context.
The rst sub-theme identi ed was motives associated with emotionaldesire. The participants cited the fact that sexual need, loss of control, pleasure and sexual fantasies as reasons to purchase sex.They explained that they turn to FSWs to satisfy their sexual needs and pleasure. This nding was in line with a study conducted in India [9] and United Kingdom [14] which indicated that, sexual need as men appealed to visit commercial sex. This might be due to the fact that when there is a sexual need, the brain releases a neurotransmitter known as acetylcholine. This, in turn triggers the release of nitric oxide into the arteries of the penis, causing them to expand and rapidly ll with blood, which urges the need for sexual intercourse. To satisfy this needs higher education male students may visit female sex workers.
The second theme was the participants' motives related to experiential desire. In this study a number of the study participants discovered their principal motive of visiting FSWs seemed to lie in the potential to undertake and learn new things. Amongst those males who drew speci c attention to the attractiveness for sex with experiential functions would generally be created to lifestyles that had been enjoyed before they were married or once they were younger. This nding has supported by a report of the book referred to as "The Continuum Complete International encyclopedia of Sexuality' that discovered fty fth of male students signed to the concept that men ought to have some sexual expertise before wedding [15].The high experiential need for sex in these study participants can be because of the very fact that half of them hadn't previous sexual history.
The third theme elucidated from the data was motives associated with academic, time and money context. Some participants believed that their motives to buy sex were aligned with their academic, nancial and time context. They expressed turning their face to FSWs when they had tension, disgusting academic result, money and time. This con rmed the ndings of the study on gender relations and risks of HIV transmission in South India [9] which revealed that there is a relationship between academic stress and the motives of visiting female sex workers. This might be due to the fact that, sex helps to relieve stress by raising endorphins and other hormones that boost mood and as a form of exercise, it can also help calm you down.
The fourth sub-theme was motives associated with Socio-environmental context, which encompasses peer pressure, alcohol in uence and easy accessibility of female sex workers. Almost all study participants stressed, the strong in uence of peer pressure on their involvement in buying sex. They explained peer pressure was always tough to deal with, especially when it comes to sex.Some higher education male student decided to have sexual relationships with female sex worker because their friends think sex is cool.This might be because of some higher education male students nd it easier to give in and have sex than to try to explain why not.
Furthermore, participants reported Alcohol consumption and female sex workers' accessibility were also cited as reasons for buying sex. Similarly, researches indicated how much alcohol a person can drink directly affects how likely they are to have unsafe sex. On average, every 0.1 milligrams per milliliter increase in study participants' blood alcohol levels raised their probability of getting unprotected sex by ve percent, the studies found [15]. Consistently, a quantitative study conducted in the southern region of Brazil about the association between the risk of alcohol use and unprotected sex in adolescents indicated 47.3% of adolescentsstated that alcohol use before having sex [16].Easily accessibility of FSWs also another socio-environmental context that pushes male higher education students to buy sex which is in line with nding of the study conducted in India [9]. This may be the re ection of the characteristics of shortcut obsessed generation.
The fth sub-theme that known as family/romantic partner/campus girl connected context include the loss of family management, break up of a romantic relationship, loss of trust on female, demanding nature of campus girl were the explanations of male higher education students urges to go to a female sex workers. This nding was in line with the study nding that showed association between family management and sexual behavior of youths [17].This may ow from to the actual fact that at a personal level, parenting and family structure was found to have an effect on young people's sexual behavior by in uencing children's self-assurance and mutual ability.
Regarding the breakup of love relationships and loss of trust in females, higher education male students indicated they bought sex to forget their previous partner. This may well be due to the idea that, having sex with as many ladies as attainable could be a great way to urge over a breakup.

Limitation of study
Due to sampling design drawing inference is impossible

Conclusions
In this study, sexual needs, sexual fantasies, experiential desire, peer pressure, substance use, low academic result, availability of time and money, loss of family control, break up with a romantic partner, loss of trust on girls and demanding nature of campus girls were identi ed and reported by the participants as the reasons why they visited female the sex worker. Therefore, the major implication of these study ndings is giving attention to the reproductive health of higher education male students is curial.

List Of Abbreviations
FSWs-Female Sex Workers, HBV-Hepatitis B Virus, HCV-Hepatitis C Virus, HIV-Human De ciency Virus, STIs-Sexual Transmitted Infections Declarations Ethical approval and consent to participate Ethical clearance was obtained from Addis Ababa University, School of public health ethical review board. After a detail explanation of the purpose of the study, verbal and written consent was obtained from each study participants. Participants who were refused to participate in the study were not being forced and participants can withdraw from the study at any time. Con dentiality of the study subject was maintained.

Consent for publication
Not applicable Availability of data and material All relevant data are within the manuscript

Competing interests
The authors declare that they have no competing interests Funding Self Authors' contributions NE; carried out the research drafting, design, statistical analysis, interpretation and manuscript writing as well as coordinating all activities in the research, MK; commented and did relevant correction on the draft manuscript. Both authors read and approved the nal manuscript.