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Imran Morhason-Bello, a Consultant in the Department of Obstetrics and Gynaecology, University College Hospital (UCH), Ibadan and Clinical Epidemiologist, is currently leading studies on different sexual behaviours and the risk of Human Papillomavirus (HPV)-associated cancers in women and men, including people living with HIV in Nigeria. In this interview with SADE OGUNTOLA, he shares findings on sexual relationships and orientations in Nigeria. Excerpts:
F ROM your studies, what are the changing languages and types of sex that you discovered in the community?
Over the years, studies have shown that the definition of sex is changing. At the outset, what people define as sex is from the perspective of penile-vaginal sex, and this has also been corroborated by national data from different countries. It is usually described in the context of a heterosexual relationship, which is a relationship between males and females.
However, in high-income countries, sex has now been broadened to penetrative and non-penetrative sex. Penetrative sex includes penile-vaginal sex, oral sex and anal sex. Non-penetrative sex includes self or mutual masturbation and, finally, the use of other materials like sex toys, otherwise known as ‘adult game’.
On sexual orientation, there is a subtle difference between the phenotypic classification and the sexual orientation. Many people are aware of the LGTBQ community which has existed for years, especially in western countries. Of course, they are still being repressed in many of the low- and medium-income countries, including Nigeria, because of the law against them.
But it is apparent that a lot of people in Nigeria are clandestinely involved in same-sex relationships while others are engaging in both heterosexual and same-sex relationships. For example, there are people that have physical attributes of men who have sexual partners that have physical attributes of women as a wife/girlfriend, but they also have another man as their sexual partner. That means that they are engaging in a bisexual relationship. Within the same heterosexual relationship, there are people that prefer to engage in penile-anal sex in addition to the penile-vaginal sex commonly associated with such sexual relationships. The most common reason given especially by young people is adventure or to satisfy their sexual fantasies.
Now oral sex can be given or received. Oral sex is when somebody uses the mouth or any part of the mouth, including the tongue, to touch the genitals of another human being, which could be of the same or opposite sex. So, somebody who is using the mouth to touch the genitals of another person is said to be giving oral sex, whereas the person whose genitals are being touched or stimulated with mouth or tongue is receiving oral sex. This type of oro-genital sex could occur within a same-sex relationship or in a heterosexual relationship.
Also, the same sex relationship between a boy and another boy or a man and another man is called men that are having sex with men, otherwise known as MSM, which some people colloquially call gay. Whereas, oral sex could also mean people using their tongue or their mouth to touch the anal verge of another person (anolingus), and that again could be a form of oral sex, and this is also practiced by individuals involved in heterosexual relationships and those within same-sex relationships.
Do we have data on the different sexual orientations in Nigeria?
Prior to the study that we did in Ibadan, I led a systematic review of published studies on different types of sexual activities in Sub-Saharan Africa. Our review covered published articles on sexual behaviours in adolescents and adults for more than 10 years. Based on the review, oral sex is as high as 47 percent in adolescents and adults. Anal sex is between four to 47 percent of young people in the general population. Of course, these were studies in which we could not ascertain the methodology around the definition of the different sexual orientations.
In fact, these studies may have underreported cases because, as a follow-up to the systematic review, a qualitative study in some local governments in Ibadan found that the majority of young boys and girls interviewed had at one time or another performed oral or anal sex with their sexual partners. Although, they were silent on their sexual partners while others were more direct in sharing the sexual orientation of their sexual partners.
And the majority of these participants said they were engaging in these behaviours because they want to protect their virginity, because they do not think that oral and anal sex is sex and, of course, it is also a form of adventure. They have read about it and have also devised a way of discussing these things among themselves without allowing adults or their parents to know by using slang.
For example, somebody may say “Oh, I just licked the plate of that person.” One of them narrated his experience as follows. “My parents wondered why I should be using my tongue to lick a plate when I said it at home, not knowing that I was discussing how I gave my girlfriend oral sex.” The boy said they bursted into laughter when his parents left because they never knew that they were talking about oral sex. Some of them said “I have taken the banana from that person.” This slang is more common among ladies, meaning that she has sucked the penile shaft of her boyfriend.
Moreover, these terminologies they also used to profile and shield themselves from people assessing them. So in terms of the prevalence of sexual activity that is happening within the community, it is wide.
Now, we found that a lot of adults engage in non-penetrative sex, particularly men and women whose partners are around the peri-menopausal age. Sexual activities can be divided into either low libido or high libido and either of the two partners make up by engaging in masturbation. They either self-masturbate, which is called self-masturbation, or both of them engage in what we call mutual masturbation because they have erectile dysfunction or sexual dysfunction and are ashamed to come and seek help. This is more common among older men who carry young girls. Because they could not have a sustained erection, they would rather pay a young lady to masturbate while they also masturbate. That is called mutual masturbation. And, of course, a lot of women and men are beginning to also use sex toys in Nigeria. These sexual activities are quite common.
How can they play safe when involved in these different forms of sexual activities?
There is no form of sexual activity that is safe if it is not responsibly practiced. Safe sexual activity is engaging in sexual activity in such a way as to either prevent a sexually transmitted infection or an unwanted pregnancy. These sexually transmitted infections are broad, ranging from bacterial to viral infections. The viral infection includes HIV and the human papilloma virus (HPV). HPV can lead to cancer if it is not cleared over a long period of time.
There are sexually transmitted infection clinics, or special treatment clinics (STC) where people can get information from experts on how to live responsibly, safely and enjoy their sexual life.
But the issue of preference is a personal choice and clinicians are not supposed to be judgmental. It will not be a professional thing. What is important is to share what the research says, and then individuals should take the information and interpret it.
Are there treatments to take regularly to remain free of sexually transmitted infections?
Of course, anyone who wants to engage in safer sexual practices needs to have good knowledge about the risks associated with each of these practices. There is information out there on how to prevent sexually transmitted infections and how to live well to minimise all these risks. What’s also important is that there are also habits that people engage in that increase the risk of engaging in unsafe sexual practices. For example, people who engage in the use of illicit drugs, excessive alcohol, and sex-enhancing medications may not know the limits.
They may think energy is the same as sexual satisfaction; that is what many people think of as sexual satisfaction. Many talk about sexual satisfaction in terms of erection and the number of sexual partners they engage per day. But there is no way you will engage in such sexual activity and remain safe without the risk of acquiring infections.
People that do twosome or threesome, do they come out to talk about it? Is it suggestive of a medical problem?
Well, there are so many people that come to me and discuss their sexual activities based on our past publications of the different sexual orientations in the community. There are people that I quietly offer service to when they come asking for advice. But people’s sexual orientation is more of an individual thing. What is important is for us to give information to people, make all these resources available and let them know the dangers associated with their actions. So, the judgment is not for us to determine.
What are the dangers associated with these different sexual orientations?
There is the risk of infection, genital injuries, HPV-associated cancer, and even financial burdens because if they acquire infection, they would have to run many tests, use medication and may be cut off from the work environment for some time. The money that was supposed to be used to feed or do other good things will be used to treat complications.
The other members of the multidisciplinary research team in Ibadan include Professor Isaac Adewole, Professor Olufemi Ogunbiyi, Dr Akinyele Adisa, Dr Adeola Fowotade and Dr Adekunle Daniel. We are working in collaboration with a team of scientists led by Professor Lifang Hou, Professor Robert Murphy and others in Northwestern University, USA and won several grants to look at the effects of HPV infection on different associated cancers. First, we are looking at the epigenetics of oral and laryngeal cancer in people living with HIV. Two, we are looking at the barriers and access to cervical cancer screening using HPV genotyping triage. Lastly, we are looking at the epigenetics of anal HPV in women who have a cervical HPV infection or cancer. We will be recruiting potential participants (men and women) in 11 other teaching and specialist hospitals in Nigeria that have or at risk of oral and oropharyngeal cancers and a community-based approach for self-sampling for cervical cancer.
