SEXUALLY TRANSMITTED DISEASES (STDs) are dramatically increasing at a rate of 15.81% per year in China and have become a serious social and health problem in this most populous country in the world. 1,2 According to a report by the United Nations Population Fund (UNFPA), 3 people aged 15–24 years are at the highest risk for STDs and the prevalence of STDs is highest among them. A review of the literature concerning STDs in India suggested that as many as 25% of the patients attending government STD clinics were younger than 18 years old. The vast majority of the males attending such clinics reported that their first sexual intercourse occurred before the age of 18 years. 4 Since 1980, attitudes about sexual behavior have changed in China, and premarital sexual activity among adolescents has markedly increased. An earlier report stated that 15% of college students had participated in premarital sexual activity. 5 Similarly, an investigation of 50 universities in Shanghai showed that 16.8% of female students and 18.8% of male students had engaged in premarital sex. 6 Undoubtedly, the risk of STDs for adolescents was related to their unsafe sexual activities. 7 Numerous studies in developing countries have shown that young people are not well taught about contraception and disease prevention, and they often have misconceptions about reproduction. 8
In order to obtain background information for further research on interventions, a cross-sectional study was conducted from June to July 1999 at Beijing Normal University to investigate patterns of premarital sexual activities and related factors among students. It was believed that the findings could provide important information for policy-makers and program managers to use in establishing health education policies, so that appropriate interventions can be implemented. An additional aim was to heighten the level of awareness and understanding among university students of the value of practicing safer sex to reduce the risk of transmission of STDs.
The cluster sampling method was used in the current study. Fifteen of 17 departments in the university were recruited. One or two classes in each department were selected, and all undergraduate students and unmarried postgraduates in the selected classes were recruited to participate in the study. A total of 2050 students were enrolled after their informed consent was obtained.
The questionnaire for this study was designed mainly on the basis of the literature and information gathered from several group discussions with students at the university, and it underwent several modifications. The feedback from group discussions suggested that the majority of students would respond more honestly about their sexual activities with an anonymous questionnaire.
In this study, the term sexual activities included masturbation, kissing, and sexual intercourse. The questionnaire mainly covered the demographic characteristics of students, their knowledge of STDs, their attitude about premarital sexual activities, their sexual behavior, and their use of condoms. Some questions were open-ended, such as “Please list the STDs you have heard of” and “Please list the measures preventing STDs.” For easy data-processing, each open-ended question was coded before data input.
Teachers and university authorities were not involved in administering the questionnaire. The self-administered, anonymous, structured questionnaires were distributed by trained interviewers and returned by self-sealed envelopes within a specified time limit.
Of the 2050 questionnaires distributed, 1967 forms were collected and 1952 were valid for data entry. Because 139 students did not identify their sex, only 1813 of the questionnaires were included in the analysis described in this article.
Among the respondents, 891 were male and 922 were female. The ages ranged from 17 to 26 years. The mean (±SD) age of respondents was 20.93 ± 1.71 (21.17 ± 1.73 for males and 20.71 ± 1.67 for females). In response to the questions measuring knowledge of STDs, 81.9% of the students were able to name at least one STD, indicating general recognition of STDs. However, knowledge of preventive measures was relatively low: only 62.3% of the students were able to list at least one measure for preventing STDs. Approximately 18% of students could not name an STD, and 38% could not list any preventive measures. Female students’ knowledge about STDs was significantly greater than that of the male students (chi-square value = 19.65;P < 0.01) (Table 1).
The following percentages of students were able to name specific STDs: 67.8%, AIDS; 54.1%, syphilis; 45.5%, gonorrhea; 5.6%, condyloma acuminatum; 0.8%, genital herpes; and 0.1%, chancroid. The following percentages of students were able to list specific prevention measures: 40%, having a single sex partner; 22%, using condoms; 12%, not sharing a wash-pool with others; 3%, avoiding transmission of blood; 3%, avoiding intimate contact with persons who have an STD; and 2%, not taking drugs.
The attitude toward premarital sexual activities was determined as well. As indicated in Table 2, 83.4% of respondents agreed that premarital sexual activities are normal among university students, whereas 16.6% disagreed. Approximately 15% believed that premarital sexual intercourse among university students was socially acceptable. The responses of males and females to this question differed significantly (males, 17%; females, 13%; chi-square value = 8.7;P < 0.01). However, there were no statistically significant differences between males’ and females’ responses to the questions about whether kissing and masturbation are normal behaviors.
Forty-one percent of students reported participating in one of the premarital sexual activities defined in this study: 28%, kissing an opposite-sex partner; 19%, masturbation; and 12%, sexual intercourse. There were significant differences between males’ and females’ reports of masturbation (chi-square value = 12.79;P < 0.01) and sexual intercourse (chi-square value = 14.71;P < 0.01). For instance, approximately 15% of male students answered that they had had sexual intercourse, whereas only 9% of female students gave that answer. There was no significant difference between males and females in terms of their responses about kissing experience (Table 3).
Table 4 shows that of the students who had had premarital sexual intercourse, 68.8% had used condoms and 29.7% had never used any contraceptive methods; 1.5% did not answer this question. Condom use was reported by approximately 70% of male students and 67% of female students who had had intercourse. The difference was not statistically significant (chi-square value = 0.30;P = 0.583).
HIV infection and AIDS have become a major social and public health problem worldwide. Since 1985, when the first patient with AIDS was reported in China, the number of AIDS cases in that country has increased rapidly. According to a national report, there were 11,170 HIV-positive people and 338 AIDS cases in China by the end of September 1998. The number of HIV infections throughout the world reached 34.3 million by the end of 1999. 9 The escalating problems of STDs, HIV infection, and AIDS have alarmed World Health Organization officials and the Chinese government. The main means of transmission in China are drug injection and unsafe sexual behavior. Transmission through sexual intercourse has become more important in recent years. 9 According to an official Chinese report in 1996, the number of commercial sex workers nationwide had reached 420,000. However, experts admitted that the actual number was possibly 10 times greater than that reported. 10 The proportion of HIV-positive people infected through sexual intercourse is increasing rapidly in China. Young people are more likely to develop AIDS or acquire STDs because they are more likely to be exposed by unsafe sex or drug abuse. It was estimated that half of all HIV infections occur among people younger than 25 years old. 11 Consequently, the sexual behavior of youths and the outcomes of these behaviors have become a major public health concern. Previous surveys in Beijing, in 1992 and 1996, showed that approximately 5.3% and 3.9% of students, respectively, had had sexual intercourse. 12 The current study, at Beijing Normal University, showed that 12% of the students are sexually active and indicated that the percentage of university students engaging in premarital sexual intercourse has increased over time. Although these percentages are still not comparable with those in developed countries, where a much higher percentage of adolescents have premarital sexual intercourse, 13,14 the traditional culture and conservative attitude in China toward premarital intercourse are becoming challenged with economic development and the introduction of western culture.
The results of this survey show that most of the students favored premarital sexual activities. Moreover, approximately 15% of them expressed a belief that premarital sexual intercourse could be socially acceptable. All these data indicate that the attitude of young people in China about premarital sexual activity differs from that of the previous generation, and this change cannot be ignored.
It is well recognized that using condoms is one of the most effective ways to prevent the spread of STDs. The results of this study indicated that a large portion of the student population has limited knowledge about STDs and their prevention. Therefore, it is essential that young people who have engaged in premarital sexual activity be aware of the importance of disease prevention and of practical measures to protect themselves from STDs.
There are several reasons why so many students in China do not know about protection measures or use them during sexual intercourse. First, public education is still limited because of the conservative culture, but attempts to educate young people through the media have begun (yet often are embarrassing). Second, research efforts and supportive resources have been insufficient. Few facilities provide condoms to the public, so accessibility of condoms—especially for young, unmarried persons—is limited. According to Blanc and Way, 15 adolescents are unlikely to use a contraceptive the first time they have sex, and adolescent females are more likely than older ones to experience contraceptive failure. Therefore, the importance of public education emphasizing safer sex among college students to prevent STDs should no longer be ignored by health officials and social workers.
In conclusion, a comprehensive reproductive-health education program in response to the pressing needs of college students must be promoted aggressively in China. The program should give students an understanding of risk behaviors, safer sex practices, the importance of reducing the risk of acquiring and transmitting STDs, the correct use of condoms, and the importance of their consistent use. In addition, the program should educate students about contraception options to enable them to choose one on the basis of their personal needs and circumstances.
1. Zhang JY. STDs prevalence in China: the past, present and future. Chung Hua Liu Hsing Ping Hsueh Tsa Chih 1998; 2: 118–121.
2. Gong XD, Wang QP, Jiang WH. Epidemiologic status and analysis of STDs epidemic in China. Chinese J Prev Control STD/AIDS 1998; 4: 186–189.
3. United Nations Population Fund, Geneva World Population Status. Beijing: Chinese Population Publishing House, 1996.
4. Awasthi S, Nichter M, Pande VK. Developing an interactive STD-prevention program for youth: lessons from a North India slum. Stud Fam Plann 2000; 31: 138–150.
5. Wu JQ, Zhao PF, Lu H, et al. The Progress of Social Sciences in Reproductive Health. Beijing: Chinese Population Publishing House, 1996.
6. Li H, Zhang KL. The progress of social behavior sciences related to HIV and AIDS. Chin J Prev Med 1998; 2: 120–124.
7. Liao SS. HIV in China: epidemiology and risk factors. AIDS 1998; 12 (suppl B): S19.
8. World Health Organization, UNICEF. A Picture of Health: A Review and Annotated Bibliography of the Health of Young People in Developing Countries. Geneva: World Health Organization, 1995.
9. Zhang KL, Xia DY. Current situation and perspectives of AIDS. J Reprod Med 2001, 10: 3–5.
10. Zhang KL. AIDS prevention. J Reprod Med 1999; 8: 204.
11. Gorgen R, Yansane ML, Marx M, Millimounou D. Sexual behavior and attitudes among unmarried urban youths in Guinea. Intl Fam Plann Perspect 1998; 24: 65–71.
12. Zhu Q. Chinese tradition and culture are the basis of policy on HIV/AIDS prevention and control in China. In: Chinese Sexology Association, eds. Sexology and Health. Chinese Population Publishing House, Beijing, 1997:7–13.
13. Herold JM, Valenzuela MS, Morris L. Premarital sexual activity and contraceptive use in Santiago, Chile. Stud Fam Plann 1992; 23: 128–131.
14. Ford NJ, Hallidy J, Little J. Changes in sexual lifestyles of young people in Somerset, 1990–1996. Br J Fam Plann 1999; 25: 55–57.
15. Blance AK, Way AA. Sexual behavior and contraceptive knowledge and use among adolescents in developing countries. Stud Fam Plann 1998; 29: 106–116.