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Michail Alexandrov Okoliyski, Ph.D., and
Petko Velichkov, M.D.*

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*Communications: Michail Alexandrov Okoliyski, Ph.D., National Center of Public Health, Sofia, Bulgaria; mental @; Petko Velichkov, M.D., Human Sexuality Research Foundation, Sofia, Bulgaria; sexology @;
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  1. Basic Sexological Premises 115
  2. Religious, Ethnic, and Gender Factors Affecting Sexuality 116
  3. Knowledge and Education about Sexuality 116
  4. Autoerotic Behaviors and Patterns 118
  5. Interpersonal Heterosexual Behaviors 118
  6. Homoerotic, Homosexual, and Bisexual Behaviors 119
  7. Gender Diversity and Transgender Issues 119
  8. Significant Unconventional Sexual Behaviors 119
  9. Contraception, Abortion, and Population Planning 120
  10. Sexually Transmitted Diseases and HIV/AIDS 121
  11. Sexual Dysfunctions, Counseling, and Therapies 124
  12. Sex Research and Advanced Professional Education 124
  13. Conclusion 124
  14. References and Suggested Readings 124

*A Note for Researchers:  The numbers included in the section titles in the Contents above refer to the page numbers in the print edition of the CCIES. For the convenience of researchers, an Adobe Acrobat (PDF) file of this chapter is available for download above (click the PDF icon), which reflects the actual pagination of the book. This will allow scholarly writers to cite actual page numbers in the printed book for quoted material, as well as its availability on the Web and the URL if desired. See also How to Use This Encyclopedia.

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Demographics and a Brief Historical Perspective


A. Demographics

Bulgaria is located in southern Europe, with Romania and the Danube River on its northern border, the Black Sea on the east, Turkey and Greece on the south, and Macedonia and Yugoslavia on its western border. With a total landmass of 42,823 square miles (110,910 km2), Bulgaria is slightly larger than the state of Pennsylvania. The terrain is mostly mountainous, with lowlands and rolling hills in the north and southeast. The Balkan Mountains cross the center of the country, east to west. The Rila, Pirin, and Rhodope Mountains are in the west and south. The climate is temperate, with cold damp winters and hot dry summers. Nearly two fifths of Bulgaria’s land is arable, and a fourth of this is irrigated, mostly in the southeast during the dry summer season. About a fifth of the country is pastureland and one third forested. Over the centuries, the strategic position of Bulgaria and Turkey in the Balkan Peninsula enabled the two nations to control a key trade and migration route between Europe and the Middle East.

According to the latest national survey (National Institute of Statistics (NIS), March 1, 2001), Bulgaria had a population of 7.98 million. Since the previous census in 1992, the population has declined by 6.6%. (All data are from The World Factbook 2002 (CIA 2002) unless otherwise stated.)

Age Distribution and Sex Ratios: 0-14 years: 14.6% with 1.06 male(s) per female (sex ratio); 15-64 years: 68.5% with 0.97 male(s) per female; 65 years and over: 16.9% with 0.72 male(s) per female; Total population sex ratio: 0. 94 male(s) to 1 female

Life Expectancy at Birth: Total Population: 71.5 years; male: 67.98 years; female: 75.22 years

Urban/Rural Distribution: 69% to 31%

Ethnic Distribution: Bulgarian: 83.6%; Turk: 9.5%; Roma (Gypsy): 4.6%; Macedonian, Armenian, Tatar, Gagauz, Circassian, and others: 2.3% (NIS 2001; CIA 2002)

Religious Distribution: Bulgarian Orthodox: 83.8%; Muslim: 12.1%; Roman Catholic: 1.7%; Jewish 0.8%; Uniate Catholic: 0.2%; Protestant, Gregorian-Armenian, and other: 1.6% (1998 est.)

Birth Rate: 8.05 births per 1,000 population

Death Rate: 14.42 per 1,000 population

Infant Mortality Rate: 14.18 deaths per 1,000 live births

Net Migration Rate: –4.74 migrant(s) per 1,000 population

Total Fertility Rate: 1.13 children born per woman

Population Growth Rate: –1.11% (2002 est.); –1.14% (NIS 2001 est.)

HIV/AIDS (1999 est.): Adult prevalence: 0.01%; Persons living with HIV/AIDS: 346; Deaths: < 100. (For additional details from, see end of Section 10B.)

Literacy Rate (defined as those age 15 and over who can read and write): 98%; attendance for nine years of compulsory school; education is free and compulsory from age 6 to 16

Per Capita Gross Domestic Product (2001 est.) (purchasing power parity): $6,200; $5,720 (NIS est.); Inflation: 7.5%; Unemployment: 17.5%; 21.7% (NIS est.); Living below the poverty line: 35%; 21% (NIS est.)

B. A Brief Historical Perspective

About 3500 B.C.E., the Thracians established the first civilization in what is now known as Bulgaria. In the fourth decade C.E., this region became part of the Roman Empire. As the Roman Empire declined, the Goths, Huns, and Avars moved in. In the 6th century, Slavs from what are now northwest Ukraine and southeastern Poland settled the region. In 679 C.E., the nomadic Bulgars from central Asia crossed the Danube River from the north and took control of the region, blending with the Slavs. The first Bulgarian kingdom was established in 681 and gradually became the most powerful state in the Balkans. Under Simeon I, who ruled from 893 to 927, Bulgaria experienced a golden age, as Macedonia, Albania, Serbia, and other parts of the Byzantine Empire came under its influence. In 865, Boris I adopted Orthodox Christianity. Between 893 and 1280, the Bulgars twice conquered most of the Balkan Peninsula. In 1396, the Ottoman Turks invaded the land and made it a Turkish province until 1878. Bulgaria’s position on the northern border of Turkey made its occupation by the Ottomans particularly harsh and inescapable.

In 1878, after winning the Russo-Turkish War (1877-1878), Russia forced Turkey to give Bulgaria its independence. Fearing the growing influence of Russia and Bulgaria in the Balkans, European powers intervened at the 1878 Congress of Berlin and fashioned Bulgaria’s territory into a small principality ruled by Alexander, a nephew of the Russian Czar.

Prince Ferdinand of Saxe-Colburg-Gotha succeeded Alexander and declared Bulgaria a kingdom independent of Russia in 1908. After losing the Second Balkan War (June to August 1913) and all the territory it had gained in the First Balkan War (1912-1913), Bulgaria joined Germany in World War I. After being defeated in World War I, Ferdinand abdicated in favor of his son in 1934-1935. After joining the Germans in World War II, Bulgaria switched sides when Russia declared war on Bulgaria in September 1944. In three days, Russia took control of the country and installed a communist regime. The People’s Republic of Bulgaria was officially established in 1946. Communist domination ended in 1990 with multiparty elections and movement toward political democracy and a free-market economy. High inflation, unemployment, corruption, and crime have been problems in recent years. In 2000, Bulgaria started on the path to eventual integration into the North Atlantic Treaty Organization (NATO) and the European Union (EU).

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1. Basic Sexological Premises

A. Character of Gender Roles


The social stereotypes concerning gender roles in Bulgaria are highly influenced by the long-lasting patriarchal tradition. Nevertheless, there are some considerable variations according to ethnic groups. In the present day, one can find some remnants of a patriarchal (men rule) model among the Turks, Armenians, Jews, and Gypsies. In general, Bulgarians did not subscribe to a macho style of social functioning. Ethnopsychological research has shown that the male domination was quite limited mostly in its outer expressions. Usually, Bulgarian men never made any major decision concerning the family’s well-being without asking the opinion of their wives. In most families, women were (and often still are) the treasurers of the family’s wealth. This kind of relationship was idiosyncratic for Bulgaria, but was not specific for the rest of the Balkan Peninsula (Panov 1914).

B. Sociolegal Status of Males and Females

The United Nations Convention on the Rights of the Child is the fundamental principle of the Child’s Protection Law. To monitor and enhance the implementation of this law, a State Agency for Child Protection has been in operation since October 2002.

During the totalitarian regime (1944-1989), great emphasis was put on the women’s emancipation. However, Bulgarian women were already accustomed to such a model, as by the end of the 19th and the beginning of the 20th century, during three successive wars, when men were permanently absent for years, the country’s economic output retained a peacetime level. Women successfully substituted for men as manpower in all kinds of labor.

In the present day, the concept of equal rights between the sexes is guaranteed by the Constitution. Article 6, paragraph 2 reads: “All persons shall be equal before the law. There shall be no privileges or restriction of rights on the grounds of race, nationality, ethnic self-identity, sex, origin, religion, education, opinion, political affiliation, personal or social status or property status.” This principle is further elaborated in the legislation and is valid for the entire legal system of Bulgaria. The age of consent in Bulgaria is 18 years.

The Constitution also regulates the protection of motherhood, the recognition of its social function, and the joint responsibility of men and women in parenthood. According to article 14, “the family, motherhood, and childhood shall enjoy the protection of the State and society.” Article 47, paragraph 2 reads: “Mothers shall be the object of special protection on the part of the State and shall be guaranteed prenatal and postnatal leave, free obstetric care, alleviated working conditions, and other social assistance.” Either spouse can benefit from postnatal leave.

The Republic of Bulgaria is a party to most international instruments on human rights, as well as to international conventions on the rights of women such as the Convention on the Elimination of All Forms of Discrimination against Women, the Convention on the Political Rights of Women, the Convention on the Nationality of the Married Women, the Slavery Convention, the Convention for the Suppression of the Traffic in Persons and the Exploitation of the Prostitution of Others, as well as to most of the ILO Conventions regarding the labor conditions of women.

Many women’s nongovernmental organizations (NGOs) have been registered in this country and, especially, during the last decade. Their aims include promoting the accomplishments of women in social life and the observance of their rights, elaborating and implementing programs and projects on the problems of women, their development, and progress, engaging in cultural, educational, charity, and international activities, and assisting women in business, scientific, and research work. Finally, they provide legal and psychological assistance to victims of violence, and so on.

The Penal Code contains a number of provisions related to violence against women. The relevant chapters titled “Crimes Against the Person” and “Crimes Against Marriage, Family and Youth” contain provisions directly concerning women, like abduction of a female person for the purpose of forcing her to enter into marriage (article 177, paragraph 2) or a parent or other relative receiving a consideration to permit his or her daughter or relative to conclude a marriage (article 178, paragraph 1); violating an obligation to a spouse or relative in an ascending or descending line, who is incapable of caring for him- or herself, and thereby placing him or her in a position of serious embarrassment (article 181); entering into marital relations with a female person under the age of 16 (articles 190, 191, and 192); persuading a female person to practice prostitution or abducting a female person for the purpose of her being placed at the disposal of others for acts of lewdness (articles 155 and 156), and so on. Legislation is envisaged to protect women from sexual harassment and exploitation of their economic dependence or low status in the workplace (Boskova 1998).

A recent public poll has demonstrated that Bulgarian men show strong approval for the existing egalitarian model. Only 6.7% of men expressed a negative attitude toward women’s emancipation. The same research demonstrated equal representation of both sexes in the structure of the workforce: 46.7% women and 53.3% men. There were no significant differences in the educational level according to sex, although women’s pay is nearly 30% less than men’s. One possible explanation is that most women are employed in agriculture, textiles, and sewing manufacturing, education, healthcare, and other highly underpaid areas (Sociology Agency “Pleades 2002”).

C. General Concepts of Sexuality and Love

The socioeconomic and moral values in Bulgaria tend to vary, and hence, the growing variety of sexuality concepts and constructs, as well as the ways they are expressed.

Since ancient times, women’s ideal was to raise children and maintain coziness in the family’s home. Men were expected to ensure material comfort and protection. At that time, the tribal tradition of marriage was quite liberal (Draqganov 1984). The pairbonding process was based on mutual attraction and love. If pregnancy occurred, then marital rituals were performed (Kaloyanov 1995). In the pagan tradition, both male and female sexuality was highly prized, which is demonstrated by an unusually affluent erotic folklore (Sheytanov 1932).

In 865 C.E., Bulgarians adopted Christianity and the society switched to the Judeo-Christian patriarchal model. This transition was rather slow and was disrupted by the forced conversion to Islam of a significant portion of the population during the 14th to 19th centuries.

With the industrialization of the country in the 19th and 20th centuries, the patriarchal family model gave way to the nuclear family. Actually, the serial monogamy model is on the rise. A plausible reason behind this phenomenon might be the very high—and mostly unrealistic—expectations of modern Bulgarians toward partnership, marriage, parenthood, and children. Love, friendship, and material comfort are the key factors to a marital relationship. In 66% of families, both spouses rank love first as a reason for their marriage, 23% rank friendship first, and only 9% rank material comfort first “Pleades 2002”).

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2. Religious, Ethnic, and Gender Factors Affecting Sexuality


A. Source and Character of Religious Values

The strongest religious values among Bulgarians are rooted in Orthodox Christianity, although some vague reminiscences of the ancient pagan tradition are adding some nuances. The common Bulgarian folk have not been famous for their religiousness. As a rule, the religious doctrine is subject to rather down-to-earth interpretations, and fanaticism or fundamentalism is not prized at all. The restrictive attitude toward sexuality has vanished with the patriarchal morality.

B. Source and Character of Ethnic Values

The contemporary Bulgarian nation is a highly rich ethnic blend. Various cultures with their specific ethics have met and blended in this land, which has always been at a crossroad between the Western world and the East, as well as between the North and the South. Hence, the diversity in attitudes, ranging from pronounced openness and tolerance to moderation in sexual matters.

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3. Knowledge and Education about Sexuality


A Caution: The short and deep political and economic changes of recent years in Eastern Europe have created a difficult situation regarding sexual behavior and AIDS prevention in Bulgaria. On the one hand, rapid modernization and the opening to the West have created an overabundance of new sexual options (pornography, commercial sex work, the self-identification of sexual minorities, etc.). On the other hand, there is no public education on the dangers of the new sexual freedom, no sex counseling, no educational literature, no outreach to persons at risk, or no concerted prevention effort. According to this situation of poverty and crime, there are some cynical voices in Bulgaria that would claim it is unnecessary to spend effort and money on empirical scientific and prognostic studies about social risks. But when we search for answers to these problems only in the “here and now” perspective without trying to learn about people’s attitudes and behaviors, it is clear that the results of the health prevention programs will be negative. Under these circumstances, it is very difficult to run scientific studies. Given this reality, the picture of sexuality in Bulgaria provided in this chapter is based on the few studies and surveys available, namely:

  • 2002: Overview of HIV/AIDS in South Eastern Europe. International Organization for Migration (I.O.M.) and UNICEF.
  • 2000: A.S.A. A representative high school students survey of Sofia and the country. United Nations Development Program/Mental Health (UNDP/MH), conducted by A.S.A.; Sofia sample—761 students; national sample—1666 students; 9-12 grade. Comparative data for Sofia are for a comparable age (16-year-olds).
  • 1999. Conditions of AIDS prevention in Bulgaria. Michail Okoliyski, Humboldt University (Dissertation), Berlin,
  • 1996: Reproductive Behavior Family Planning. Contraceptives Use. (An empirical sociological survey directed by Mihail Mirchev). A.S.A.-MH, Ministry of Health, The Phare Programme, Sofia (Mirchev, Jachkova, Kasakova, Velikova).
  • 1995: National Health Center. A NHC Representative Survey of Sofia (1044 respondents, 9-11 grade).
  • 1995: AIDS and Sexuality; a study based on a representative sample for Sofia on 15- to 17-year-olds. The Agency for Socioeconomic Analyses—A.S.A., June-July, 1995.
  • 1992: Argirova, R., D. Beschkov, O. Troschev, E. Bodscheva, V. Georgieva, The AIDS Experience, AIDS-Centre, Sofia.
  • 1988: Medical Academy Representative Survey of Sofia (1100 respondents, 9-11 grade).

A/B. Formal and Informal Sources of Sexual Knowledge

There is very little sex education for Bulgaria’s youth in the schools and at home.

For effective AIDS prevention among Bulgaria’s youth and others target groups, health professionals need insights into the behavior patterns and motives that hide behind epidemiological data. In order to gain a better understanding of sexual knowledge, attitudes, and practices in Bulgaria, Michail Okoliyski (1999) undertook a survey using face-to-face interviews on the “Conditions of AIDS prevention in Bulgaria” during his doctoral studies at the Humboldt-University in Berlin under the scientific guidelines of Prof. Erwin. J. Haeberle. The resulting dissertation is the result of the analysis of an initial survey of IV-drug users, persons with homosexual, bisexual, and heterosexual behavior, and people who are selling sexual services. Although the survey respondents were not a representative sample, their responses can provide, with caution, some insights into the sexual attitudes, knowledge, and behaviors of Bulgarians in general. The study was conducted in the period 1997-1998 in the capital city of Bulgaria, Sofia.

Of those answering Okoliyski’s questionnaire, 84.7% received their sexual knowledge from friends, with 20.3% through the media. Only 15.3% received sex education from their parents. This confirms the claim of many Bulgarian educators that sex is still a taboo subject in most Bulgarian families. The fact that only 13.6% learned anything about sex from their teachers reflects the general absence of sex education in Bulgarian schools, where students are taught a total of only two hours about the biological differences between the sexes. There is a total lack of formal education with regard to the psychological and social aspects of sex. As a result, Bulgarian adolescents feel abandoned by their elders as far as their own sexual problems are concerned. They still get their sexual knowledge “in the streets” (see Table 1).

Table 1                  

Sources of Sexual Knowledge

  Parents School Friends Media
Bisexual behavior 6.7% 20.0% 80.0% 6.7%
Homosexual behavior 15   % 5   % 85   % 25   %
Heterosexual behavior   15.4% 15.4% 92.3% 23.1%
IV-drug use 27.3% 18.2% 81.8% 27.3%

Knowledge about HIV/AIDS is obtained in a quite different way. Most Bulgarians learn about it from the media, since friends and peer groups are largely uninformed because of a lack of any intensive government campaigns. Again, parents and schools play a very modest role, illustrating once again the inadequacy of formal sex education. There is one relative difference between our target groups, however. Persons with bisexual and homosexual behavior receive more AIDS information from their friends and peer groups (see Table 2).

Table 2                  

Sources of Information about HIV and AIDS

  Parents School Friends Media
Bisexual behavior 6.7% 6.7% 73.3% 40.0%
Homosexual behavior 5   % 30   % 50   % 75   %
Heterosexual behavior   14.3% 14.3% 21.4% 71.4%
IV-drug use 16.7% 8.3% 16.7% 66.7%

The ideas of sexuality and sexual behavior in the youth population in Bulgaria are becoming more and more pragmatic. In 2000, 15.2% of 16-year-old students in Sofia do not agree that sex without love is useless (A.S.A. UNDP/MH 2000). Five years ago, they were 12.2% (NHC 1995), and in 1988, just 8.2% (Med. Academy Represent. Survey Sofia 1988). There are changing attitudes towards using commercial sex services. A third of the students (from the national sample) support a possible legalization of prostitution, and 6.7% state they have used commercial sex.

According to the same survey, 11.2% of students who have an active sexual life have a positive attitude to accidental sexual contacts, and the attitude to this is that 7.8% are neutral. In other words, 19% of the sexually active teenagers consider accidental sexual contacts permissible. Even more informative is the fact that 33.4% of surveyed students who have a sexual life would under certain circumstances take part in group sex.

There is an abrupt rise in positive attitudes towards condom use, but it is not accompanied by actual behavior. At the same time, the share of respondents who would not insist with their partner on condom use remains at the 1995 level and even increases by 2% (see Table 3). In 2000, the attitude that condoms reduce sexual pleasure is still the greatest obstacle to their use. The share of students who do not share the opinion rises in comparison with 1995 by only 4%. Factors such as feeling embarrassed to buy a condom are no longer valid—over 60% of students would not feel embarrassed to buy a condom (see Table 4).

Table 3                  

Would You Refuse Sexual Contact If Your Partner Would Not
Use a Condom?

  1988 1995 2000 (16-year-olds)
Definitely yes    13.1%    16.8% 22.9%
I think yes 14.3% 22.6% 19.9%
I cannot say 38.8% 26.8% 26.3%
I think I would not insist 19.9% 20.2% 15.3%
I would definitely not insist   13.9% 13.6% 15.7%
Source: Medical Academy, 1988; NHC/ASA, 1995; UNDP/MH/ASA, 2000;
Comparable Sofia Samples.

Table 4                  

Do You Think That Condom Use Makes Sexual Intercourse

  1988 1995 2000 (16-year-olds)
Definitely yes    14.2%    14.0% 12.3%
I think yes 13.9% 17.2% 10.2%
I cannot say 52.5% 35.9% 38.1%
Probably not 10.6% 16.4% 18.6%
Definitely not   8.7% 16.4% 20.8%
Source: Medical Academy, 1988; NHC/ASA, 1995; UNDP/MH/ASA, 2000;
Comparable Sofia Samples.

HIV/AIDS awareness among Sofia students in 2000 is almost the same as in 1995. Indicators of awareness such as the understanding that the disease is incurable and that a week after sexual intercourse, transmitted virus cannot be identified are rising. The basic knowledge that the virus is transmitted through sperm, blood, and vaginal secretions remains at the same level for all samples (76% to 78%).

At the same time, there are indications that anal sex risk-awareness is decreasing. In 1995, 39.8% of 15- to 16-year-old students in Sofia were aware that anal intercourse is the riskiest one, while only 32.9% of same-age students know that today. At the national level, this knowledge is common for 36.8% of high school students. Additional analyses failed to confirm the hypothesis that lowered awareness of anal sex risk is connected to the higher tolerance to homosexuals in the last few years.

HIV/AIDS awareness, as with prevention attitudes, depends on the type of school, size of settlement, and ethnic background. Thus, for instance, the knowledge of the long latent period of HIV is common for 35.7% of vocational school students, 51.1% of secondary school students, and 70.0% of high school students. Other indices do not show such substantial differences among students in vocational and secondary schools. The basic line of division is between vocational and secondary schools, on the one hand, and high schools, on the other.

Understanding of the subjective HIV-infection risk is an important indicator of awareness of the problem. Available data show little development in the understanding of the subjective HIV-infection risk. The majority (50%) of students do not worry that they personally can be infected. On the national level, only 19% perceive HIV as a big danger and are thinking about that. An important fact is that this attitude is higher in smaller settlements and teenagers of families of lower social and economic status. Additional analyses show an important connection between HIV/AIDS unawareness and subjective risk perception. Thus, for instance, teenagers, who are not aware that the HIV virus is transmitted through blood, sperm, and vaginal secretions, perceive this risk as higher. Therefore, we are not talking so much about awareness of the problem, but rather about the higher level of concern, which is always connected to less awareness.

Be it so, this concern has changed only a fraction in the last five years. And this is only natural from the point of view of insignificant changes in HIV/AIDS awareness. Nevertheless, there is a slight increase in subjective risk perception in the last 12 years (see Table 5).

Table 5                  

How Big Is the Possibility That You Will Become AIDS Infected?

  1988 1995 2000 (16-year-olds)
No risk exists    26.1%    27.7% 21.4%
The risk is small (I am not worried) 46.5% 42.0% 40.3%
There is some possibility 15.5% 21.0% 22.2%
The risk is considerable, I often think  
  about it
9.1% 5.7% 10.7%
There is very big possibility   3.6% 5.3%
Source: Medical Academy, 1988; NHC/ASA, 1995; UNDP/MH/ASA, 2000; Comparable
Sofia Samples.

However, this is just one side of the gradation that shows how often students received information from one source or another. It must be mentioned that such data are to a large degree conditional. Respondents tend to point to sources that should inform and not the ones they actually used. A significant fact is that the influence of information sources in Sofia is different from that for the country as a whole.

Despite this conditional status of the data, it is evident that the influence the same channel (information source) exerts in Sofia and in the countryside is different. Obviously, the influence potential of Sofia schools is higher than that of the countryside. On the other hand, friendships in the province are probably closer and more influential.

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4. Autoerotic Behaviors and Patterns


Only a minority of the respondents of the Okoliyski survey made between 1998 and 1999 reported not engaging in this sexual practice (see Table 6). Also, the intensity and the frequency of the masturbation were high: About two thirds of the respondents practice sexual self-sufficiency (self-stimulation) more than once a week. The survey data show that the sexual self-sufficiency and the mutual partner masturbation (hand and body massage) are an important part of the sexual lives of these people. Although these sexual practices are used mainly in connection with other sexual variations, they are an important part of the sexual lives of these people.

Table 6                  

How Often in the Week Do You Practice Masturbation?

  Never More than once Every day Several times daily
Bisexual behavior    20.0% 73.3% 0% 6.7%
Homosexual behavior 10   % 75   % 15% 0%
Heterosexual behavior   35.7% 64.3% 0% 0%
Drug users 33.3% 66.7% 0% 0%

[Comment 2003: Sex therapists have noticed a bullish tendency of acceptance towards sexual self-gratification, especially among single males. In married couples, male as well as female masturbation is perceived as some kind of deviation rater than a sign of the couple’s malfunctioning (Archives of Human Sexuality Research Foundation (H.S.R.F.) unpublished data). (End of comment by P. Velichkov)]

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5. Interpersonal Heterosexual Behaviors

A. Children

[Comment 2003: Very little is known about children’s sexuality in Bulgaria, and no research has been carried out on this topic. [End of comment by P. Velichkov)]

B. Adolescents


Some ethnic differences have been perceived concerning menarche and the age of first sexual intercourse for females (see Table 7). The average age at which male adolescents start their sex life is 16.1 years (Tzekov 2003).

Table 7                  

Estimated Age of Menarche and Sexarche (2003 Estimates)

  Age at Menarche Age at First Sex Contact
Roma girls   12.2 14.6
Turk 12.8 15.4
Bulgarian 13.5 16.8

C. Adults

Marriage, Affairs, and Divorce


The institution of marriage, in Bulgaria, is in a transition as more than one fifth of the households are in fact couples in a steady relationship without official marriage. Thus, in 2002, about 40% of the children are born of some kind of nonmarital relationship. As the marital index, currently at 4 per 1,000—half the rate of 20 years ago—is plunging down, it is only natural for the divorce index to be affected at a lower rate. Thus, when the number of officially registered marriages decreases, implicitly the probability for divorce also decreases, but not at the same pace of 1.3 per 1,000 (Belcheva 2002).

Sexual Satisfaction


It has been established that 63% of women in the age range of 20 to 31 years, cohabiting with a male partner, had sexual intercourse two or three times weekly. Among married women in the same age range, less than 20% attained such a frequency. In the tenth year of marriage, 38% of husbands are not happy with their marital sex; of them, 43% of men rank as a first cause the diminished interest of their wife toward sex; 67% of wives declared that they had been solicited for sex more frequently than they would have wished to be “Pleades 2002”).

Sexual Relationships


A significant majority of people were in a committed (unpromisk “non-promiscuous”) sexual relationship: 65.6% were with a partner-relationship; 26.2% were without a partner-relationship; and only 29% of the respondents have more than one partner at the same time (Okoliyski 1999) (see Table 8). There are also some changes in the quantitative parameter of the partner relationships in recent years, with a decrease in the number of sexual partners.

Table 8                  

Adult Sexual Relationship Partner Situation*

Drug Use
I live in a partner-relationship 73.3% 50% 78.6%   66.7%   65.6%
I live without a partner-relationship 0% 45% 21.4% 33.3% 26.2%
I have more than one partner at the same time 26.7% 5% 0% 8.3% 8.2%
*confirmative answers.

Incidence of Oral and Anal Sex


Anal sex, fellatio, and cunnilingus are not subject to any restrictions, provided they are practiced between consenting adults. According to therapists, anal sex in heterosexual relationships is almost exclusively initiated by the male. Nowadays, fellatio and cunnilingus are willingly accepted by most couples as an element of their loveplay. Cunnilingus is regarded as a must by most men with premature ejaculation (H.S.R.F.).

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6. Homoerotic, Homosexual, and Bisexual Behaviors


Respondents in the Okoliyski 1999 survey engaging in same-sex and bisexual behavior were very ambivalent toward their own sexuality: 46.7% of the sample with bisexual behavior and 75% of the respondents with homosexual behavior were negative about their own sexuality (see Table 9). In our opinion, this statistic shows that they did not consider their sexuality as a common part of human sexual behavior. Since the late 1960s and early 1970s, homosexual activity between consenting adults is no longer prosecuted. This decriminalization was an official step toward emancipation of the sexual minorities made under the totalitarian regime. As we know from other researchers, two types of commercial sex workers do appear to be at risk of HIV transmission. In the first place, those without a self-identity, and in the second place, those resulting from isolation and stigmatization; the absence of social support and control may discourage condom use. Anyway, unsafe sex practices may result from this lower degree of institutionalization in prostitution, which may result in unsafe sex practices.

Table 9                  

Is Your Sexual Behavior Acceptable to Society?


Drug Use   
Yes 40   % 20% 71.4% 50   %
No 46.7% 75% 7.1% 33.3%
I don’t know     3.3% 5% 21.4% 6.7%

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7. Gender Diversity and Transgender Issues


A search into the archive of the former sexology outpatient clinics has shown that, for a 35-year period, gender-conflicted clients composed only a tiny share of the patient population, only 0.1%. A total number of 47 persons were transsexuals looking for sex reassignment. Among them, as many as 38 were female-to-male patients and only 9 were diagnosed as male-to-female transsexuals. (The fact that more than half of the biologically male transsexuals emerged during the first seven years following the abolishment of the dictatorship may suggest some socioeconomic explanation to the striking discrepancy of the male/female ratio.)

Twenty-three persons, 15 female and 8 male, obtained a legal sex reassignment procedure. After at least one year of “adaptation” period, 21 patients (14 female and 7 male) proceeded with a sex-reassignment surgery. (The first operation in Bulgaria on a female-to-male transsexual after a legal sex reassignment was performed in 1988 by an andrologist and plastic surgeon team.

Two of the transsexuals decided not to undertake surgery. They felt comfortable and satisfied with the legal change of their sex alone and have not pursued surgery. The follow-up on the operated patients demonstrated a beneficial effect mostly on the quality of their lives.

Actually, there are no special legal regulations concerning transsexuals. Sex-reassignment procedures are performed on transsexuals within the existing legal framework that is being routinely applied to intersexual cases. The court presumes that sex assignment at birth, exclusively based on the appearance of the external genitalia, may be inaccurate (H.S.R.F. unpublished data).

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8. Significant Unconventional Sexual Behaviors

A. Coercive Sexual Behaviors


One of the most acute social problems to emerge during the political transition period is the increase in the national crime rate, which in the late 1990s reached unprecedented levels. For example, in 1989, the number of annually registered crimes was only 663 per 100,000 persons, while over the next 10 years this figure annually approximated 3,000 per 100,000. Crime is among the major sources of distress and concern of the population (see Table 10). Women in particular have become affected increasingly. Since the mid-1990s, the number of women who have been victims of crime has risen by over 60% (United Nations 2001).

Table 10                  

2001 Crime Statistics

Totals 24,291 28,729
These totals included:
  Crimes against the person, comprising:
1,735 1,819
    Debauchery 328 325
    Rape 139 164
    Crimes against marriage, family, and youth 969 952
*The number of Crimes and Convicted persons do not match because sentences are
pronounced on crimes committed during previous years.

B. Prostitution


Sexual Behavior of Commercial Sex Workers (CSW)

Under the Bulgarian penal legislation, persons who organize or distribute sex services are subject to penalty. Women introduced to this activity are not subject to penalty. Article 156, paragraph 1 of the Bulgarian Penal Code provides a penalty of 10 years in prison and a fine of up to BGN100 for anyone convicted of kidnapping a person of the female sex to commit her to obscene activities.

The legal status of prostitution determines to a large degree the non-transparency of researching and understanding thereof. The Epidemiological Control and Surveillance System does not record the professional status of infected people. It is even less possible to do that with regard to female prostitutes. However, a number of subgroups of women can be separated according to the different types of prostitution:

Street and Highway Prostitution

These are girls who work on the outside, in central and peripheral city and town areas—railways and bus stations, streets, highways, border and roadside motels, and TIR parking lots. They are known as “crew girls.” The majority are of Roma (Gypsy) or Turkish descent, young, low-educated, with no health or sexual education. Characteristic behavior models include parental violence, selling the girl into the business, or total exploitation of her income by the procurer or the whole family. The factor that makes this group one of the highest risk groups is “regular customers.” With the flow of time, the girls start to regard them as reliable partners and, therefore, lower safety measures when serving them. Another factor is different cultural and religious attitudes to safe sex and condoms that some of the multinational customers have. A specific subgroup is notable—the group of “transit girls,” who travel with one customer from border to border, and then either return with their next customer or go to a third border. This extremely high mobility, as well as supposedly low typical level of working conditions and safety, turns it into one of the highest risk groups with regard to both HIV/STD risk and physical safety.

Hotel Prostitution. Hotels have a constant contingent of attending girls with set prices and working hours. In the summer, some of them are sent to the seaside “on business trips.”

Companion Clubs. This business is under tight control. The tariffs of all clubs offering sex services are strictly uniform. The girls are aged 18 to 22. They come from all social strata—schoolgirls and college-girls, as well as married working girls who work as call-girls. Beside Bulgarians, the clubs employ many foreigners, mainly Russian and Ukrainian. Characteristics of the clubs are unconditional safety measures and condom use; medical examinations and testing are obligatory, according to certain information.

Unofficially, there exists another subgroup of elite prostitutes. Closely related to the high levels of the business organization, they and their work gain no publicity. They are called “escort” girls.

Sociological data regarding CSWs were gathered by the Health and Social Environment Foundation for the years 1997 to 1999. These data were collected in face-to-face interviews with “highway” CSWs using standardized questionnaires. The 1997 survey covered 167 girls working in Lom, Russe, and Sofia. The 1998 and 1999 follow-up surveys covered 63 and 66 CSWs, respectively, in the same places. The surveys were held within the framework of this project and the AIDS on Wheels project. The results were:

  • Age: More than 10% of the girls were below age 16. Thirty to 50% were 16 to 18 years old. The other two age groups, 18 to 22 and over 22 comprise 40% of the women.
  • Education: Elementary education was the prevailing level of education—with 40.1% of the group members. Girls who have primary and secondary education form equal proportions of the commercial sex workers—24% each.
  • Ethnic Background: Bulgarians form the largest ethnic community within the group—46.7% of the interviewees described themselves as Bulgarians. Of ethnic minorities, girls of Roma background form a 33.5% share, Bulgarian Muslims 6.6%, and 5.4% are Turkish. A not-so-small share of Roma girls describes themselves as Bulgarians.
  • Marital Status: 23.4% of the interviewees were divorced, 7.8% were single, 6% were married, and 5.4% stated they were living with a friend/constant partner.
  • Social Background and Material Status: most of the group representatives are of lower social and economic status—unemployed or low-paid or unskilled workers. Most of the village girls come from families of farmers. These data apply mostly to women working on the outside.
  • Health Care Related Behavior: No stable habits of going for prophylactic examinations were observed. For over a third of the women, the reason to seek healthcare was health disorders. On the other hand, more than 85% of the women admitted that no one had ever prevented them from seeing the doctor, regardless of whether they had had a health problem or wanted to have a prophylactic examination. Attitudes toward the quality of services offered by the respective health facilities should also be accounted for. The general attitude toward healthcare is positive. Confidence in the preservation of personal secrets, however, is low.

C. Pornography and Erotica


Pornography was prohibited in Bulgaria until 1989. That means there was no such business or market. But interested individuals could obtain some imported materials at their personal risk.

After the last political changes in the early 1990s, the pendulum switched to the other side and pornography flooded the market, although it could still be prosecuted. The trick is that the law does not specify what exactly pornography is, and so the business and the merchants are offering only “erotica.” In 13 years, the interest in pornography and its market has visibly shrunk.

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9. Contraception, Abortion, and Population Planning


A. Contraception

As soon as abortion on request was legalized in the mid 1950s, it became the most common form of birth control in this country.

Nowadays, 76% of the women admit to using some kind of contraception. However, there are a great variety of methods according to socioeconomic status. A small portion of the well-to-do women (middle class included) has access to modern contraception. The rest benefits predominantly from the calendar method, withdrawal, and condoms (in order of frequent use). (Data supplied by V. Tzekov, expert in gynecology at the Human Sexuality Research Foundation).

There are very few NGOs that provide contraceptive means for the needy, and when they do, this is on a rather irregular basis.

See data on condom use in Section 10, Sexually Transmitted Diseases and HIV/AIDS.

B. Teenage (Unmarried) Pregnancies

Each year, about 5% of Bulgarian women in their fertile age give birth between ages 15 and 19.

C. Abortion

First-trimester abortion on request is legal, provided it takes place in a state medical institution, and post-abortion contraceptive counseling is legally required. In 2002, an estimated 41.2% of pregnancies were terminated by an abortion (V. Tzekov, expert in gynecology at Human Sexuality Research Foundation, unpublished data).

D. Population Programs

Studies show that economic hardships have encouraged negative tendencies in reproductive and sexual behavior, hence, a negative population growth. The two-children model is still present among Bulgarians, but only as an unattainable ideal. So far, no effective pronatalistic policy has been elaborated and implemented in this country (Belcheva 2002).

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10. Sexually Transmitted Diseases and HIV/AIDS


A. Sexually Transmitted Diseases

STD Trends

The rate of sexually transmitted non-HIV/AIDS infections, which is an indicator of HIV infection, has increased over the last ten years. Since 1990, there has been an alarming trend in the number of syphilis cases. Whereas, in 1990, the number of newly recorded syphilis cases was 378 (4.5 out of 100,000), in 1999, there were 2,509 new cases (30 out of 100,000). According to the World Health Organization (WHO) criteria, some regions of the country are on the verge of an epidemic outbreak. The hepatitis B and C infection rates in Bulgaria are several times higher than that in some European countries. The large number of chronic cases resulting in disability and death, combined with the considerable expenditures for their treatment, make them socially and economically important.

Condoms and Safe and Unsafe Sexual Practices

Detailed data were collected by the first author from respondents concerning the types and safety of their sexual contacts. Respondents were asked about their specific sexual acts. The vast majority of the people with heterosexual, bisexual, and homosexual behavior, in general, often used condoms; only the group of the intravenous drug users used condoms very inconsequently—66.7% of them performed unsafe coitus and cunnilingus. Half of the drug users were willing to perform fellatio without the protection in order to secure money for drugs. This group of drug users represents diverse segments of the population, who, in turn, are characterized by inconsequent and low frequencies of condom use, a high prevalence of STDs, and inadequate knowledge of the basic concepts of HIV transmission and prevention (see Table 11). About 50% of the respondents indicated changes in their sexual behavior because of AIDS (see Table 12), but there is the potential danger of infection with HIV for about half of the respondents who do not use condoms regularly (see Table 13).

Table 11                  

Sexual Practices of Intravenous Drug Users, With and Without Condoms During the Last Sexual Relations*

  Not practiced With condom Without condom
Vaginal intercourse (Coitus) 0% 33.3% 66.7%
Masturbation/Body massage   0% 0% 100   %
Cunnilingus 33.3% 0% 66.7%
Petting 20   % 0% 80   %
Fellatio 50   % 0% 50   %
Anal sex 90.9% 0% 9.1%
Group sex 100   %
Sadomasochistic sex 100   %
*confirmative answers

Table 12                  

Changes of Sexual Behavior


Drug Use

Yes      60% 50% 64.3% 59%      49.2%
No 40% 50% 35.7% 50% 50.8%

Table 13                  

How Often Do You Have Condoms When You Are Going Out?


Drug Use
Always 73.3% 40% 28.6% 16.7%
Sometimes    20   % 35% 35.7% 25   %
Never 6.7% 25% 35.7% 58.3%

Evaluation of Condoms. A series of questions were asked to elicit beliefs and attitudes about condoms. In fact, the opinion of the respondents on condoms was predominantly negative.

Frighteningly, nearly half the respondents report that they do not use condoms regularly, 27.3% report that when they use alcohol or drugs, they do not care about AIDS, and 41% said they usually do not use condoms (see Table 14).

Table 14                  

Attitudes to Condoms*

Drug Use
I use condoms because of
66.7% 50% 50   % 16.7% 47.5%
I don’t use condoms 33.3% 40% 42.9% 50   % 41   %
When I use alcohol/drugs,   
  I don’t care about AIDS
21.4% 15% 33.3% 50   % 27.3%
*confirmative answers.

Condoms were not only inconsequential in use, but they also are not always available for the commercial sex workers. The respondents did not seem to consider accessibility or cost to be important obstacles to condom use, but nearly 21% reported that they never have condoms when going out and 29% said condoms were sometimes unavailable when needed; 50% always have condoms.


HIV/AIDS History and Current Status

The first HIV-positive case in Bulgaria was diagnosed 18 years ago, in 1989. At the start of the epidemic in the country (1985-1986), in most of the cases the virus was imported from Africa, and the infection sources were sailors who had had sexual intercourse in the ports of Zaire, South Africa, and other African countries.

In 1986-1987, all hemophiliacs living in the country were subjected to obligatory testing, and 11 HIV-positives were found among them. They were probably infected before 1985 (i.e., before testing of each donated blood unit was introduced).

A few years later, after 1991, the picture was totally changed. At present, in over 70% of the time, transmission is from an infected Bulgarian citizen to another person within the country.

Bulgaria is still considered a low HIV/AIDS-prevalence country. By May 15, 2000, there had been registered a total of 287 HIV-positive people—75 of whom have AIDS—and 73 AIDS deaths. The statistical index for the spread of the disease among adult men and women used in AIDS-related reports is 2.2—a number comparable to the figures for Africa. Analysis of the distribution of the registered HIV-positive cases by sex shows that 70% of the infected are men and 30% are women. In 2000 (May 15), the number of newly registered HIV-positives was 17, 14 of whom were men (82.3%) and 3 were women (17.7%).

Analysis of age distribution shows the majority are men aged 20 to 40, and, in particular, 21 to 30 year olds. Another worrying fact is that about 7% of HIV-positives are aged 15 to 19.

Among people living with AIDS in the period from 1977 to 1999, most affected were people in the active age—15 to 49 year olds (93%), with 7% over 50 years old; 67% of the people living with AIDS are men. There are no people living with AIDS aged 0 to 14.

The main mode of transmission in our country is sexual transmission—83%, mostly heterosexual—about 70% of the HIV-positive cases. Infected blood transfusions account for 14%, and mother-to-child transmission for 1%. So far, there have been registered 8 HIV-positive injecting drug users. Until 1993, there were no HIV-positive injecting drug users.

A comparison of these data with published data about the mode of transmission in developed countries shows considerable differences (WHO, Weekly Epidemiological Record, 74:409-420). The main mode of transmission in industrialized countries is homosexual/bisexual (37%), followed by heterosexual (32%), transmission through injecting drug use (26%), transmission through blood transfusion (25%), perinatal infection (1%), and other (1%).

Regarding the geographical distribution of HIV-positive cases in the country, it is notable that the biggest concentration of infected people is found in the following cities: Sofia 65, and Burgas 59 (mainly sailors working on fishing ships, who have stayed for a long time in African ports and had heterosexual relationships there). The number of HIV-positive cases in the city of Burgas continues to rise also through intracity transmission. There are 19 HIV-positive cases in Varna. The number of HIV-positives in Gabrovo is 18 and has remained constant since 1993, although, since 1997, there have been registered 2 or 3 connected cases. Then come the cities of Plovdiv with 16, Stara Zagora with 13, and others. The Ministry of Health states that the distribution by regions of the newly registered cases by May 15, 2000, was as follows: the city of Sofia: 5, Haskovo: 2, Lovech: 2, and 1 HIV-positive person in each of the regions of Sofia, Blagoevgrad, Dobrich, Pleven, Gabrovo, Silistra, and Plovdiv. The HIV virus has spread among almost all social groups and professions, though, regretfully, not all registered HIV-positive people declare their profession. A large number of them have been transferred to less physically demanding jobs following recommendation by the state.

The WHO record ranks Bulgaria seventh of the ten countries most at risk of infection over the next 10 years. Based on the prognosis, if effective measures are taken now, the HIV epidemic could be contained in Bulgaria.

The health experts revealed the main determinants in the rapid growth of HIV/AIDS infection in Bulgaria. The following factors directly affect the infection rate: risky sexual behavior (unprotected sex); high incidence of sexually transmitted infections; and risky injecting drug use practices (shared needles and syringes). Some of the indirect factors are: poverty (economic insolvency); prostitution; drug and alcohol abuse; low health awareness; low general education of some vulnerable groups; and high (labor) mobility. The lack of an overall policy addressing high-risk behavior and HIV/AIDS prevention, as well as the ineffectiveness of the relevant institutions, agencies, and services, and the transition are other indirect factors.

In medical practice, blood products and invasive procedures pose the highest risk. Among the indirect factors are: lack of standards and good practices, and insufficient skills for diagnosis, consultation, and treatment of HIV/AIDS.

C. Most Vulnerable Groups

Several groups have been identified by UNICEF and the International Organization for Migration (I.O.M.) (2002) as the most vulnerable to HIV/AIDS and STDs.

Adolescents and Young People

The analysis indicated that young people have not developed sufficient social and life skills necessary for making responsible decisions about their sexual activities. Statistics show a marked increase in the number of ever-younger individuals engaging in risky behavior—not attending or dropping out of school, being unemployed, engaging in juvenile crime, prostituting themselves (especially those aged 16 to 24), abusing drugs (particularly injecting drugs), abusing alcohol and smoking, and engaging in risky sexual practices. The number of young girls who are pregnant for the first time (mostly unwanted and/or unplanned) and the abortion rate in Bulgaria are significantly higher than in other countries in Europe. Registered STD cases, including syphilis, are rapidly increasing. In fact, people under the age of 24 account for most of the registered HIV cases.

Injecting Drug Users

Over the past few years, the number of injecting drug users has increased consistently. Currently, the number of the HIV-positive cases among injecting drug users in Bulgaria is comparatively small. However, experts indicate that there is an enormous risk of a dramatic increase of HIV among this population in the near future. One indicator is the high rate of hepatitis B and C among them. In addition, many injecting drug users engage in risky sexual behavior. Methods for early detection of the virus among injecting drug users are necessary to prevent the rapid spread of the virus through unsafe injecting practices.

Prostituting Women and Men

This is a non-homogeneous and difficult-to-access group, which is highly vulnerable to HIV/AIDS and other STDs. The risk factors include: the criminal element of the commercial sex business, violence and trafficking, marginalized social status, risky sexual practices, and social stigma.

Men Who Have Sex with Men

There are three main subgroups within the gay community: the elite, which is highly restrictive; the middle, which is mobile and versatile with a high rate of mixing; and the lowest subgroup, composed mainly of outsiders and Roma. This subgroup is especially vulnerable. It is mobile with the lowest level of information, which makes intervention difficult. They engage in very risky sexual practices, they seldom use condoms, and many of them prostitute. The men-who-have-sex-with-men community as a whole is vulnerable to HIV/AIDS and other STDs because of several risk factors: inconsistent condom use, multiple casual sex partners, and relatively short permanent relationships.

Roma Community (Gypsies)

Available information indicates that the Roma community is the most vulnerable among the ethnic minorities. This is because of a number of interrelated factors: a rapidly disintegrating patriarchal system, which is not being replaced by a new, sustainable social structure; ever increasing social isolation accentuated by a 90% unemployment rate; a poor economic culture; absence of social skills and motivation for socialization; increasing rates of prostitution, drug abuse, crime, and mobility; and other practices increasing the risk of HIV/AIDS and other STDs. In addition, health experts suggest that most Roma women have banal STDs, which increases the risk of more serious infections, such as HIV and hepatitis B.

The available data regarding the level of risk in Roma sexual behavior are limited and, to some extent, contradictory. There was a sociological survey conducted by Mirchev and ASSA-M in 1996, according to which 58% of Roma populations begin their sexual life before reaching the age of 16. But ASA data for the year 2000 show the average age of first sexual intercourse for Bulgarians in general is also 15 to 16.

The generalizations below are based most of all on experts’ observations and on impressions from the work of nongovernmental organizations that have as their priority the Roma community. These organizations include SEGA, Georgi Bogdanov and IGA, Dimitar Russenov, and the Napredak Romany Foundation (in Pazardjik). According to these organizations, Roma women begin their sexual lives at 12 and Roma men at 14 to 15. These observations were made on the Roma communities in the vicinity of Pazardjik, Plovdiv, Stara Zagora, and Sliven. At the same time, Roma NGOs consider that early entrance into sexual life is connected with early marriage. If that is true, then the early beginning of sexual life should not be interpreted as risk behavior, since it is begun with a permanent partner.

Roma NGOs emphasize that one of the important HIV-related determinants is the repressive attitude to premarital sexual behavior and sexual behavior before living together. The belief is that the value of the unstained wife provokes premarital bisexual behavior and oral and anal sex practices. The question remains whether such premarital risk behavior exists when marriage is contracted at age 12 to 14.

Impressions of the liberalization of sexual behavior are voiced, which, by the way, is characteristic for Bulgarians too (A.S.A.–UNDP/MH 2000). What is of importance is that with low awareness, the liberalization of sexual values can bring about an increase in the risk of sexual behavior. According to quoted NGOs, repressive attitudes towards sexual relations with members of other ethnic groups decline. The opinion is that this is more valid for men than for women. Anthropological observations by Haralan Alexandrov show that Roma values impose repressive attitudes towards the sexual behavior of women and permissive ones towards that of men. This places Roma women in a status of double minority, which makes them an especially at-risk group.

NGOs have confirmed the conclusion made earlier in discussing prostitution, about the prevalence of highway and street prostitution among Roma girls. It is considered that Roma prostitutes come from the lowest social and economic strata of the community, quite often from broken families or disintegrated clans. These girls are usually brought from another settlement—at great distance from their place of work. Roma NGOs emphasize that there exist no restrictive values suppressing the business of procurers. The community is inclined to blame the guilt of prostitution on the alien girl (that comes from another settlement) rather than on the procurer—the man who brings income into the quarter. These observations have been confirmed by police officials from Pazardjik to the IGA Foundation.

Pilots and Aircraft Crews

According to a Ministry of Transport and Communication official, the sexual behavior of the mobile group of pilots and stewards/stewardesses is at highest risk with respect to the transmission of HIV or other sexually transmitted infections. Representatives of this group are in the employment of Balkan Airways, Hemus Air, Air Via, and Heli Air, the latter offering mainly tourist services in the Indian Ocean (the Maldives and Thailand). These pilots are away from their families almost throughout the year.

Statistical data about aircraft crews are available in the Ministry of Transport and Communication and the Aviopolyclinics with the Medical Transport Institute, where crews are serviced, and where certificates of professional and health fitness are issued. Experts estimate the number of pilots and stewards working for all Bulgarian airways at a little over 1,000, including people who work exclusively abroad. These estimates exclude Bulgarian pilots working for foreign airways.

Pilots’ stays abroad range from some hours to some days. The mobility of aircraft crews is increased by the fact that every member of the airways’ staff is entitled to a so-called service ticket. It is usually used with the family. It entitles them to free travel to any destination. On the other hand, in the last 6 or 7 years, the stay of aircraft crews is very limited—up to several days, depending on the routes.

According to a Balkan Airways official, risky sexual behavior is due more to curiosity than to length of stay. Balkan Airways considers this group well controlled from a medical point of view. All employees pass medical examinations on an annual or semiannual basis; this makes possible determining the level of professional fitness. Before every flight, aircraft crews pass a medical examination in a special medical room at the Sofia Airport. This is a routine medical examination, but it includes an alcohol test. Pilots are highly motivated to control their health themselves, as their job is well-paid and highly profiled: if they lose their job, they cannot find work anywhere else, all the more so now that there have been reductions lately.

The pilots and stewardesses are in good financial standing, which makes possible commercial sex contacts. In the opinion of a Balkan Airways official, many of them travel together with their lovers. On the other hand, pilots and stewardesses form an extremely closed group and maintain contacts mainly among themselves. Second-family practices do occur, but unlike sailors’ relationships, these are most often within the crew.

Isolated Groups and Imprisoned Individuals

Very often, the lack of opportunities for heterosexual intercourse, stress, altered values, violence within the group, and the lack of contact with the outside world result in risky homosexual behavior and prostitution, which increases the risk of HIV and STDs.

D. Education of Target Groups

Confusing messages about AIDS have repeatedly irritated the general public in Bulgaria. Modest government efforts have been undermined by contradictory reports in the mass media and by various journalistic horror scenarios that failed to become true. It seems that, in actual fact, the majority is hardly as well informed as it believes (Okoliyski 1999). Thus, it is striking to note that few actually change their risky behavior. For example, 66.7% of the IV-drug users believe themselves to be well informed, but only a few practice “safe sex” or “safe use.” Moreover, fewer persons with exclusively heterosexual behavior consider themselves well informed (50%), in comparison with the other target groups (drug use: 66.7%, homosexual behavior: 60%, or bisexual behavior: 60%). This can only mean that the latter groups get their information not from public campaigns, which are still mostly directed at the heterosexual majority, but from friends and peers. Finally, although a majority feels sufficiently informed, 66.5% maintain, nevertheless, that there is not enough AIDS information and AIDS counseling in Bulgaria.

The contradiction between feeling well informed on the one hand and, on the other, believing the information to be inadequate, suggests that Bulgarians, inside or outside of any particular target group, have a different concept of AIDS prevention, and expect future prevention campaigns to be different from what has been offered so far. In particular, it seems that AIDS prevention in Bulgaria should be more specifically tailored to specific groups.

[Update 2002: UNAIDS Epidemiological Assessment: As of mid 2001, Bulgaria has reported a cumulative total of 340 cases of HIV infection acquired primarily through heterosexual transmission. HIV testing is mandatory among blood donations and systematic among many subgroups of the population. Since 1992, HIV testing is voluntary for pregnant women, STD patients, and injecting drug users in treatment centers. Diagnosed HIV-infected cases are recorded in a national HIV database. Prevalence data come mostly from ongoing testing programs. The number of pregnant women tested has dropped considerably between 1991 and 1992. It is unclear whether women having abortions continued to be tested after 1991. In addition to the change in testing policy, the economic crisis in 1991-1992 resulted in a 25% drop in birthrates. The incidence of syphilis has been in the range of 20 to 30 per 100,000 over the last few years.

[The estimated number of adults and children living with HIV/AIDS on January 1, 2002, were:

Adults ages 15-49: 400   (rate: 0.1%)
Women ages 15-49: NA  
Children ages 0-15: NA  

[No estimate is available for the number of adults and children who died of AIDS during 2001.

[No estimate is available for the number of Bulgarian children who had lost one or both parents to AIDS and were under age 15 at the end of 2001. (End of update by the Editors)]

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11. Sexual Dysfunctions, Counseling, and Therapies


A study based on the records of the former sexology clinics has shown that the sex ratio of the clients is 8 males to one female. Clinic visitations initiated by both of the sexual partners together represent only 7% of all visits. Men are complaining of premature ejaculation in 48% of the cases and in 41% of some kind of erectile failure. The 11% left seek consultations for diminished sexual interest, delayed or lack of ejaculation, some orgasmic trouble, paraphilias, and so on.

Women are mostly concerned with difficult or the lack of orgasm (with or without diminished desire) in 72% of the cases, 13% with lack of sexual desire, 12% with vaginismus, and the remaining 3% are experiencing dyspareunia (coital pain), paraphilias, and so on.

The proposed treatment ranges from medicaments to some kind of psychotherapy (mostly behavioral). In the majority of cases, a combination of both is suggested.

The society is not exempt from some pejorative attitude toward sexually dysfunctional persons. However, this disposition has been on a downward trend over the past 20 years.

During the course of the healthcare reforms in Bulgaria, sexology consultations previously offered for free by the public sector were discontinued altogether. Private clinics are offering services, but their competence and level of expertise is not subject to control or certification in any way (H.S.R.F archives).

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12. Sex Research and Advanced Professional Education


As in the rest of the Eastern Block countries, the healthcare service in Bulgaria was highly centralized and exclusively state-owned and operated. Nonetheless, for more than 35 years, a few sexology clinics and a research unit were in operation. Because of a reform in the national healthcare service, since 1999, all sexology services were closed down and no alternative has been introduced.

In an effort to alleviate this adverse situation, the Human Sexuality Research Foundation was established. Unfortunately, this NGO is surviving practically with no external financial support and exclusively on voluntary principle. Postal address: 16, Kosta Lulchev Str., bl. 244. app. 36, Sofia 1113, Bulgaria; email address: sexology @

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Up until now, there has been no large-scale, systematic, and reliable research on sexuality in Bulgaria. Even if such research is carried out, it is very unlikely to demonstrate the existence of some striking peculiarity linked to the sex, sexual concepts, and practices of Bulgarian people. Because of its geographical position, the country was constantly exposed to intensive external influences by various cultures. Bearing in mind that conservatism is not a strong feature of the local mentality, one can imagine how difficult it is to keep one’s own style in sexuality unaltered.

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References and Suggested Readings

Argirova, R., D. Beschkov, O. Troschev, E. Bodscheva, & V. Georgieva. 1992. The AIDS experience. Sofia: AIDS-Centre.

A.S.A.–UNDP/MH. 2000. A representative high school student survey of Sofia and the country. Agency for Socioeconomic Analyses (ASA) & United Nations Development Program/Mental Health (UNDP/MH), conducted by ASA.

A.S.A. 1995 (June-July). AIDS and sexuality: A study based on a representative sample for Sofia on 15-17 year olds. The Agency for Socioeconomic Analyses (ASA).

Belcheva, M. 2002. Fertility and reproductive behavior. Sofia: Dunav Press.

Boshkova, L. 1998. The rights of women in Bulgaria in human rights in Bulgaria. United Nations Development Programme, Sofia; Friedrich Ebert Foundation, Sofia, Information and Documentation Centre of the Council of Europe, Sofia.

CIA. 2002 (January). The world factbook 2002. Washington, DC: Central Intelligence Agency. Available:

Draqganov, M., et al. 1984. Ethno-psychology of the Bulgarians. Sofia.

H.S.R.F. Unpublished data in the Archives of the Human Sexuality Research Foundation.

I.O.M. 2002. Overview of HIV/AIDS in South Eastern Europe. I.O.M. (International Organization for Migration) and UNICEF.

Kaloyanov, A. 1995. The Bulgarian shamanship. Sofia.

Mirchev, M. 1996. Reproductive behavior family planning. Contraceptives use (An empirical sociological survey directed by Mihail Mirchev). ASSA–M, Ministry of Health, The Phare Programme, Sofia. (Mirchev, Jachkova, Kasakova, & Velikova).

National Statistics Institute, Bulletin. 2002. Sofia.

National Health Center (N.H.C.). 1995. (National) representative survey of Sofia (1,044 respondents, grades 9-11).

Okoliyski, M. 1999. Conditions of AIDS prevention in Bulgaria. Humboldt University (Dissertation), Berlin. Available:

Panov, T. 1914. A psychology profile of the Bulgarian people. Sofia.

“Pleades 2002.” Sexes at labor and home. Sofia: Sociology Agency (In press).

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