In this study the proportion of school youth engaged in oral and anal sex is considerable about 1 in 20 youth were involved in oral and anal sex practices. Moreover, a large proportion of youths involved in oral and anal sex were not taking appropriate protection measures such as consistent condom use. Reasons mentioned for having oral and anal sex included preventing pregnancy, preserving virginity, and reducing HIV and STIs transmission risks. All individual, parental, and peer level factors were associated with involvement in oral and anal sex.
Previous studies reported a wide ranging oral sex (19.6%-78%) and anal sex (5%-54%) practices [12
]. Although the proportion of oral and anal sex in this study appears to be low, the proportion of youth engaged in multiple sexual partnerships, and the extremely low and inconsistent use of condom during such sexual encounters is a major concern. In addition, approximately 3 quarters of sexually active students in this study intend to continue having oral and anal sex in the next 6 months. This is higher than the reported 31.5% oral sex intention from America [15
]. This speaks that oral and anal sexual activity among some young people is a planned experience. However, the motives behind this intention need further scrutiny. Nearly half of the currently sexually active students received gift at the exchange of oral and anal sex. Young people engaged in transactional oral and anal sex are at high risk for STIs including HIV, because they may be less able to negotiate and make decision about the timing and conditions of sex with their partners [36
]. Therefore, sexual health educations need to be given about the dangers of oral and anal sex and the ways on how to protect themselves from STIs including HIV.
The results of this study highlight several key issues that merit further consideration by practitioners, teachers, parents, the community and peer educators. Since youth sexual behavior is interrelated, intertwined and influenced by a multitude of factors, intervention should target the individual, family and peer determinants rather than focusing on isolated individual behaviors.
Studies on individual level predictors of oral and anal sex are scarce. However, extant literatures on vaginal sex reported association of individual level variables such as self-esteem, college aspiration and attitude towards sex with engagement in vaginal intercourse [37
]. Similar findings were found in this study. Low self esteem, favorable attitude towards oral and anal sex and low college aspiration were associated with involvement in oral and anal sex. This finding underscores that parents and schools should inculcate the value of education in children starting from childhood. Interventions to garner and raise the self esteem of young people as well as changing attitudes towards safe sex should be in place.
Living with both parents was protective from oral and anal sex. This concurs with the results of previous findings [19
]. The possible explanation for this is families headed by two parents may have more time to supervise their children and might be physically and emotionally available to communicate about sexuality to their children than other family constellations. Therefore, marriage counseling and interventions targeting family life should be given consideration. Furthermore, maternal education was a strong predictor of oral and anal sexual intercourse. As a result, female education should be given sufficient consideration.
Consistent with other studies, best friend's sexual activity was a strong predictor for engagement in oral and anal sexual activity in this study [27
]. Peers are main sources of information and influence related to reproductive and sexuality issues to young people [41
]. As a result, correct, incorrect, safe, or risky information can be introduced, circulated and diffused among members of this social system. Thus, strengthening school peer education programme is a worthy investment to educate students about the risks associated with oral and anal sex and available protective measures.
Corroborating with previous research findings, the majority of the youth engaged in oral and anal sex wrongly perceived that these sexual acts provide protection from STIs including HIV [13
]. This is alarming and has serious programmatic and policy implications. Unless measures are taken to change this misperception, oral and anal sex could become the source for the next wave of HIV and STIs epidemic. Therefore, the inclusion of relevant information on sexual matters and prevention of STIs in the school curriculum is essential. The majority of the youth practicing anal and oral sex also consider these modes as means of preventing pregnancy. Although that might be true, these acts do not protect against the risk of contracting STIs including HIV. Therefore, students need to be advised on safer sexual practices. Furthermore, it is vital that schools sexual health education be comprehensive enough to cover the wider sexual experiences and educate students about the risks associated with oral and anal sex.
Approximately one in seven of the sexually active student's oral sexual debut and one in five respondent's first anal intercourse in this sample occurred before the age of 10. In addition, nearly half of oral and anal sex debut of students happened without their consent. This is higher than the results of studies in different parts of Africa [42
]. Although coerced sex may occur at any age, engagement in forced oral and anal sex at an early age, where these children are not capable to defend and protect themselves is catastrophic. Child sexual abuse is against human rights and has physical, psychological, and social consequences as well as negative impact on the education and future survival and hope of children [46
]. Thus, the prevention of child sexual abuse needs investment from government, health sector, legal, education, police, the community, and the family. Prevention through public education and school health education; early detection and treatment of victims should be in place.
The major limitation of this study is the accuracy of self reported oral and anal sexual practices of respondents. As these sexual practices are considered taboo in Ethiopia there may be social desirability bias leading to under reporting. However, attempts were made to minimize this bias by using self-administered anonymous questionnaire and ensuring privacy during data collection. Despite this limitation, the large sample size and the representativeness of the sample make the findings of this study generalizable to similar population in large urban cities in Ethiopia.