Western Journal of Nursing Research, 2001, 23(2), 211-222 Western Journal of Nursing Research March 2001, Vol 23, No Knowledge of and Attitudes Toward Sex Among Chinese Adolescents Wan-Yim Ip Janita P C Chau Anne M Chang May H L Lui This study was conducted to examine the knowledge of and attitudes toward sex of 178 Chinese secondary school students in Hong Kong The data were collected using a questionnaire that comprised three parts: the Chinese version of the Mathtech Knowledge Test, the Chinese version of the Mathtech Attitude and Value Scale, and a demographic sheet seeking sociodemographic information In general, students demonstrated a low level of sexual knowledge, especially in relation to adolescent marriage, the probability of pregnancy, and adolescent sexual activity With regard to attitudes, students indicated positive attitudes toward importance of family and importance of birth control Male students in comparison with their female counterparts had a higher level of agreement with premarital intercourse and the use of pressure and force in sexual activity In Hong Kong, little is known about the sexual attitudes and behavior of Chinese adolescents Most studies investigating Chinese young people’s knowledge and attitudes toward sex have been done on college students (Chan, 1990; Tang, Lai, & Chung, 1997) As Tompkins (1999) points out, nursing practice is effective when an exploration of the clients’ beliefs precedes nursing intervention To provide appropriate and culturally sensitive education programs to Chinese adolescents, it is necessary to assess their knowledge of and attitudes toward sex This study was, accordingly, Wan-Yim Ip, R.N., R.M.N., B.N., M.Phil., Assistant Professor, Department of Nursing, The Chinese University of Hong Kong, Shatin, N T., Hong Kong; Janita P C Chau, R.N., B.N., M.Phil., Assistant Professor, Department of Nursing, The Chinese University of Hong Kong, Shatin, N T., Hong Kong; Anne M Chang, R.N., Dip.N.Ed., B.Ed.St., M.E.D St., F.R.C.N.A., Ph.D., Professor, Department of Nursing, The Chinese University of Hong Kong, Shatin, N T., Hong Kong; May H L Lui, R.N., B.N., M.Phil., Assistant Professor, Department of Nursing, The Chinese University of Hong Kong, Shatin, N T., Hong Kong © 2001 Sage Publications, Inc 211 Downloaded from wjn.sagepub.com at East Tennessee State University on June 20, 2015 212 Western Journal of Nursing Research designed to explore the sexual knowledge and the sexual attitudes among a sample of Chinese secondary school students SEXUAL KNOWLEDGE AND BEHAVIOR Sex education has been included in the formal and informal curricula of primary and secondary schools of Hong Kong for many years (Hong Kong Education Department, 1986) A number of surveys in recent years, however, have revealed that the sexual knowledge of young people was rather limited, while the incidence of unsafe sex practice had increased (The Family Planning Association of Hong Kong, 1994, 1999; The University of Hong Kong, 1995) In a telephone survey of 1,038 randomly selected young people ages 15 to 29 years, 40% of respondents did not use condoms during sex and one in five young men had used the services of prostitutes The Family Planning Association of Hong Kong (1999), which offers an integrated medical and counseling service in fertility and sexuality for unmarried young people, revealed that the major service sought by women ages 16 to 25 was termination of pregnancy (31.4%) and emergency contraception (29.3%) These findings indicate that many adolescents have limited knowledge about sexual health SEXUAL KNOWLEDGE AND ATTITUDES Previous studies indicate that sexual behavior is influenced by a number of factors including knowledge and attitudes Chan (1990) found that increased sexual knowledge tended to be associated with the repudiation of sexual myths Yi (1998), in his study on 412 Vietnamese American college students’ knowledge of sex, reported that sexually active participants were less knowledgeable than those who were less sexually active Increase in sexual knowledge alone might not affect behavior; it is equally important to modify attitudes in designing effective sex education programs (Pleck, Sonenstein, & Ku, 1991) Educators, sociologists, and psychologists share a common framework, in which education modifies knowledge or attitudes, which in turn facilitate behavioral change (Visser & Bilsen, 1994) A World Health Organization–sponsored study (Grunseit, 1994) conducted in the United States, Europe, Australia, Mexico, and Thailand showed that comprehensive sex education programs led to safer sexual behaviors Downloaded from wjn.sagepub.com at East Tennessee State University on June 20, 2015 March 2001, Vol 23, No 213 The sex education classes in these countries could help young people to postpone sexual intercourse or, if they were already sexually active, to practice safer sex and reduce their number of partners This study also found better knowledge when sex education programs were provided before young people became sexually active and that programs with numerous options were more effective in promoting safer sexual behavior than those that promote abstinence alone FACTORS INFLUENCING SEXUAL KNOWLEDGE AND ATTITUDES Specific information about sexual attitudes and knowledge is vital to the design of effective sex education programs (Lief, Fullard, & Devlin, 1990) Cultural and social beliefs affect individuals’ attitudes toward sex, which in turn affect their sexual behavior (Bhugra & de Silva, 1993) Therefore, it is important to offer culturally sensitive sex education that addresses the common misinformation among the public Furthermore, sex education programs need to be incorporated into the total cultural system of a given country (International Council of Nurses, 1996) It is important to offer culturally sensitive sex education that addresses the common misinformation among the public In addition, demographic variables have also been found to influence a person’s attitudes toward sex (Lewis & Bor, 1994; Payne, 1976) Gender differences regarding sexual knowledge and attitude have been noted in past studies (J S Chang, Tsang, Lin, & Lui, 1997; The University of Hong Kong, 1995) J S Chang et al (1997) found that in the Chinese culture, men have always been more sexually permissive than women with respect to kissing, petting, and sexual intercourse From a sociological perspective, adolescent males have been encouraged to be active rather than passive in expressing their sexuality so as to develop ways of being in control and to structure situations to meet their own needs (Macionis, 1995) Nevertheless, the emerging autonomy for women gained from education and formal employment has exposed women to more opportunities and ideas that encourage sexual permissiveness (Chang et al., 1997) Because there are limited studies that have explored secondary school students’ sexual knowledge and attitudes, the purpose of this study was twofold: to examine secondary school students’ knowledge of and attitudes toward sex and to determine the gender differences in attitudes toward sex Downloaded from wjn.sagepub.com at East Tennessee State University on June 20, 2015 214 Western Journal of Nursing Research METHOD Design The study used a cross-sectional descriptive design to collect data from 180 Grade coeducational secondary school students prior to the commencement of a sexual health education program Study participation was voluntary Sample The participants in the study were 178 Chinese Grade students from a secondary school in New Territories, giving a response rate of 99% There were 47.2% boys and 52.8% girls The ages of the students ranged from 15 to 17 (x = 15.37, SD = 0.55), and 60.7% had no religious belief Of the students, 57% were studying science, 41.6%, art and 1.1% commercial subjects Most of the students (92.7%) reported having had no formal education on sexual health Of those 13 students having attended a formal sex education program, 10 had received it at school Whereas approximately 12.4% of the students had no siblings, 79.2% had one to two siblings Procedures Approval to conduct the study was obtained from the Research Ethics Committee of The Chinese University of Hong Kong and the secondary school All Grade students in the secondary school were invited to participate in the study during the weekly assembly The research assistant explained the nature and purpose of the study to the students, with confidentiality and anonymity being assured The students were also instructed that they were free to decline to participate in the study at any time Instruments The data were collected using a questionnaire that comprised three parts Part comprised items seeking sociodemographic data Two questions in particular sought information on whether the students had previously taken any formal courses on sexuality, and if so, where they had attended the courses Parts and were the Chinese version of the Kirby (1990) Mathtech Downloaded from wjn.sagepub.com at East Tennessee State University on June 20, 2015 March 2001, Vol 23, No 215 Knowledge Test (MKT) and Chinese version of the Kirby (1990) Mathtech Attitude and Value (MAV) Scales, respectively MKT The English version of the MKT scale (Kirby, 1990) is a 34-item multiple-choice test comprising areas: adolescent physical development, adolescent relationships, adolescent sexual activity, adolescent pregnancy, implications of adolescent marriage, the probability of pregnancy, birth control, and sexually transmitted disease One mark is given for the correct answer of each item The test-retest reliability coefficient was 89 (Kirby, 1990) In the current Chinese version of MKT, two items regarding adolescent pregnancy and abortion rate in America were omitted, as they were not related to the degree of sexual knowledge our students possess The Kuder-Richardson 20 (KR20) coefficient for the 32-item Chinese MKT in this study was 76 MAV Scale This scale is a 70-item self-report, 5-point forced choice rating measure (e.g., = strongly disagree, = strongly agree) There are 14 subscales, including the following: clarity of long-term goals (e.g., “I know what I want out of life”), clarity of personal sexual values (e.g., “I have my own set of rules to guide my sexual behavior”), understanding of emotional needs (e.g., “I know what I need to be happy”), understanding of personal social behaviors (e.g., “I usually understand how I behave around others”), understanding of personal sexual responses (e.g., “I know how I react in different sexual situations”), recognition of the importance of the family (e.g., “Families are very important”), self-esteem (e.g., “I feel that I have many good personal qualities”), satisfaction with personal sexuality (e.g., “I’m happy with my sexual behavior now”), satisfaction with social relationships (e.g., “I am very happy with my friendships”), sexuality in life (e.g., “A sexual relationship is one of the best things a person can have”), various gender role behaviors (e.g., “Women should behave differently from men most of the time”), the importance of birth control (e.g., “More people should be aware of the importance of birth control”), premarital intercourse (e.g., “People should not have sex before marriage”), and the use of pressure and force in sexual activity (e.g., “No one should pressure another person into sexual activity”) Subscale scores were derived by summing the appropriate items, with higher scores indicating higher levels of agreement with the attitudes or values (Kirby, 1990) The internal consistency of these subscales for the English version has been established with Cronbach’s alpha coefficients ranging from 94 to 58 (Kirby, 1990) The reliability coefficient for the Chinese Downloaded from wjn.sagepub.com at East Tennessee State University on June 20, 2015 Western Journal of Nursing Research 216 TABLE 1: Mean Scores and Standard Deviations for the Chinese Mathtech Attitude and Value Scale (N = 178) Overall Score Scale Attitude toward the importance of birth control Recognition of the importance of the family Attitude toward the use of pressure and force in sexual activity Understanding of personal social behavior Attitude toward various gender role behaviors Understanding of emotional needs Clarity of long-term care goals Clarity of personal sexual values Understanding of personal sexual responses Satisfaction with social relationships Attitude toward sexuality in life Satisfaction with personal sexuality Self-esteem Attitude toward premarital intercourse Cronbach’s Alpha M SD 71 62 4.24 4.14 0.60 0.59 50 73 50 56 79 66 61 71 65 59 66 91 3.78 3.56 3.55 3.55 3.43 3.43 3.31 3.28 3.24 3.11 3.11 2.90 0.61 0.67 0.61 0.54 0.80 0.59 0.50 0.73 0.62 0.42 0.42 1.00 NOTE: Each subscale consists of items version in this study for the total scale was 87 and for the subscales ranged from 91 to 50 (see Table 1) Face validity of the instruments had been assured through discussion among local experts in the field, and the instruments were considered relevant for use in Chinese culture Bilingual research assistants translated the MKT and MAV into Chinese, aiming for conceptual rather literal meaning of items Back translation was carried out by another, independent bilingual research assistant (Brislin, 1970) Discrepancies between the original and back-translated English versions were identified and modified according to the opinion of bilingual experts with the necessary knowledge to understand the implied concepts in both languages Two Form secondary school students were asked to complete the translated versions and did not report any difficulties in understanding the items Downloaded from wjn.sagepub.com at East Tennessee State University on June 20, 2015 March 2001, Vol 23, No 217 TABLE 2: The Adjusted Mean Scores and Standard Deviations for the Chinese Mathtech Knowledge Test (N = 178) Scale Number of Items Adolescent physical development Adolescent relationships Adolescent sexual activity Adolescent pregnancy Adolescent marriage Birth control Sexually transmitted disease The probability of pregnancy 3 M SD 62 67 41 70 27 47 48 37 18 34 31 30 23 21 21 29 RESULTS Knowledge of Sex The mean score for the total MKT was 15.94 (SD = 4.16) Comparison between the subscales, each with a different number of items, was facilitated by the use of the adjusted mean derived by dividing each subscale by the number of items in that subscale As shown in Table 2, the students had comparatively high scores in three knowledge areas: adolescent pregnancy, adolescent relationships, and adolescent physical development, whereas the implications of the adolescent marriage subscale had the lowest mean score In other words, the students were quite knowledgeable about physical and social aspects of sexuality but were comparatively weak in knowledge about implications of adolescent marriage Attitudes Toward Sex The means and standard deviations of MAV total and subscale scores are presented in Table The computed mean ratings ranged from 4.25 (SD = 0.60) to 2.90 (SD = 1.00) Variability of ratings across students as indicated by the corresponding standard deviations was small, ranging from 0.42 to 1.00 The highest scores were for recognition of the importance of the family and the importance of birth control Adolescents’ attitude toward premarital intercourse was scored the lowest In other words, the students place a higher value on family relationships and the importance of birth control but tended to be neutral toward the issue of premarital sex Downloaded from wjn.sagepub.com at East Tennessee State University on June 20, 2015 218 Downloaded from wjn.sagepub.com at East Tennessee State University on June 20, 2015 TABLE 3: Gender Differences on Sex Attitude Subscales Scores Male (n = 84) Subscale Clarity of personal sexual values Attitude toward various gender role behaviors Attitude toward sexuality in life Attitude toward use of pressure and force in sexual activity Attitude toward premarital intercourse NOTE: C.I = confidence interval *p < 05 **p < 01 Female (n = 94) M SD M SD t 95% C.I 16.10 17.20 16.83 2.93 3.34 3.35 17.22 18.24 15.62 2.85 2.67 2.80 –2.60* –2.31* 2.64* –.27, –1.98 –.15, –1.93 30, 2.14 18.17 12.89 3.18 4.91 19.51 15.95 2.77 4.73 –3.05** –4.22** –.46, –2.22 –1.63, –4.48 March 2001, Vol 23, No 219 Gender Differences on Attitudes Toward Sex Differences between genders were examined using t tests for the 14 MAV subscales Table shows that there were significant differences between male and female students for five MAV subscale scores, including clarity of personal sexual values, attitude toward various gender role behaviors, attitude toward sexuality in life, attitude toward use of pressure and force in sexual activity, and attitude toward premarital intercourse In other words, male students in comparison with their female counterparts had lower levels of agreement on clarifying their personal sexual values and developing positive sexual relationships but had higher levels of agreement on premarital intercourse and the use of pressure and force in sexual activity Concerning gender role behavior, female students appeared more likely to have attitudes consistent with their gender role status DISCUSSION This group of students generally had a low level of knowledge of sex, particularly with regard to the issues of marriage, sexual activity, birth control, and the probability of pregnancy The low level of knowledge about the implications of marriage while still an adolescent was not unexpected The low level of knowledge of birth control, sexually transmitted disease, and the probability of pregnancy indicated the areas that need to be addressed in the development of sex education programs The lack of such knowledge may result in young adolescents’ unsafe sex practices (Matasha & Ntembelea, 1998) In fact, these findings of inadequate sexual knowledge by the adolescents were consistent with previous research results (Chan, 1990; Chau & Chang, 1999; Shek & Mak, 1989) This phenomenon may be explained by inadequacy in the access to sources of information accessible by this group of students as only a minority had attended formal sex education in school Although the Hong Kong Education Department (1986) has advised schools to provide quality sex education programs that cover sensitive and contentious issues about sex, the findings of this current study indicate that sex education may not have been fully implemented According to Shek and Lam (1985), sex education should be regarded as a formal subject in the school curriculum in Hong Kong secondary schools The current sex education programs tend to be more ad hoc and reliant on extracurricular activities Downloaded from wjn.sagepub.com at East Tennessee State University on June 20, 2015 220 Western Journal of Nursing Research The findings that the students’ attitudes toward the majority of the items related to sexual health, particularly premarital sex, tended toward neutral suggests that the students in that group may not have formed a definite opinion about what is an acceptable or unacceptable expression of sexuality In most Chinese families, social order and control of emotions and feelings are highly valued, therefore, open discussion and expression of sexuality may be unusual for teenagers (Hirayama & Hirayama, 1986) Moreover, because attitudes toward sexuality may not be reflected in behaviors (J S Chang et al., 1997), it is necessary to investigate the sexual practice of this cultural group in future studies In this study, adolescents’ attitudes toward the importance of the family and the importance of birth control were particularly strong Family is one of the many factors that could be influential in the development of adolescent attitudes about sex (Bhugra & de Silva, 1993) Such a high level of agreement with the importance of positive attitudes toward the family was demonstrated in this study Chinese sexuality is based mainly on the Confucian and Taoist traditions, which emphasize procreation and social order, with sex for pleasure and outside wedlock being prohibited as it may break family relationships (J Chang, 1997; Ng & Lau, 1990) Besides, talking about sex is a taboo area in many traditional Chinese families, with most of the older generation’s having received no sex education themselves and not knowing how to approach the subject (J Chang, 1997) Therefore, to enhance the positive influence of the family on adolescents’ attitudes toward sex, health care professionals should provide appropriate sex education for parents who not know how to engage children in discussion on the sensitive subjects about sex The awareness of using birth control demonstrated by the adolescents in this study was relatively high, although the actual number of students who knew how to use condoms had not been recorded In another Hong Kong study by the Social Science Research Center (The University of Hong Kong, 1995), however, the actual number of adolescents who reported using condoms was lower than the number who reported their intention to use them Ignorance about condoms and the low rate of usage might lead to the spread of AIDS, STDs, and pregnancy among teenagers (Schwartz, 1996) Further studies are needed to investigate the barriers and the benefits encountered by adolescents in using condoms and other birth control methods (Hanna, 1999) Last but not least, the finding that boys were more permissive toward premarital intercourse is consistent with the finding reported by Minakshi (1997) In addition, Sue’s (1979) findings that a higher proportion of men than women fantasized about forcing others into sexual relationships may Downloaded from wjn.sagepub.com at East Tennessee State University on June 20, 2015 March 2001, Vol 23, No 221 help explain the boys’ higher agreement with the use of pressure and force in sexual activity Notwithstanding, the potential self-reporting bias should be taken into consideration in the interpretation of the results, as young boys and girls might report what they perceive to be socially desirable responses rather than report their actual attitudes (Leighton & Freya, 1992) Qualitative data might be needed to gain insight into the basis on which boys and girls formulate their responses with respect to the items Clearly, sex educators should always be sensitive to the differences between girls’ and boys’ attitudes regarding expression of sexuality and should incorporate it into the plan of sex education programs This study provides a beginning exploration of knowledge and attitudes toward sex among Chinese secondary school students The results suggest that health care professionals need to build partnerships with schools to develop appropriate sex education programs and counseling to the students In doing so, nurses should be sensitive to young people’s sexual health needs and help clarify positive attitudes and values toward sex The limitations of this study include the use of a convenience sample that reduces the ability to generalize the findings An additional limitation is the low reliability estimates of some of the MAV subscales that indicate instability in the relationships between the items in those scales Further testing of the reliability of the instrument is needed Further research on a larger sample with a wider age range would help to identify the students’ needs for sex education REFERENCES Bhugra, D., & de Silva, R (1993) Sexual dysfunction across culture International Review of Psychiatry, 5, 243-252 Brislin, R W (1970) Back-translation for cross-cultural research Journal of Cross-Cultural Psychology, 1(3), 185-216 Chan, D W (1990) Sex knowledge, attitudes, and experience of Chinese medical students in Hong Kong Archives of Sexual Behavior, 19(1), 73-93 Chang, J (1997) The Tao of love and sex: The ancient Chinese way to ecstasy New York: Penguin Chang, J S., Tsang, A.K.T., Lin, R H., & Lui, P K (1997) Premarital sexual mores in Taiwan and Hong Kong Journal of Asian and African Studies, 32(3/4), 265-283 Chau, J.P.C., & Chang, A M (1999) Effects of an educational programme on adolescents with premenstrual syndrome Health Education Research, 14(6), 817-830 The Family Planning Association of Hong Kong (1994) Report on the youth sexuality study (in school survey) Hong Kong: Author The Family Planning Association of Hong Kong (1999) Report on knowledge, attitude and practice survey, 1997 Hong Kong: Author Downloaded from wjn.sagepub.com at East Tennessee State University on June 20, 2015 222 Western Journal of Nursing Research Grunseit, K (1994) Global Programme on AIDS: Effects of sex education on young people’s sexual behavior Geneva, Switzerland: World Health Organization Hanna, K M (1999) An adolescent and young adult condom perception scale Western Journal of Nursing Research, 21(5), 621-634 Hirayama, H., & Hirayama, K K (1986) The sexuality of Japanese Americans Journal of Social Work and Human Sexuality, 4, 83-85 Hong Kong Education Department (1986) Guidelines on sex education in secondary schools Hong Kong: Government Printer International Council of Nurses (1996) Healthy young people = a brighter tomorrow Geneva, Switzerland: Author Kirby, D (1990) Sexuality questions and scales for adolescents Stockton, California: ETR Associate Leighton, K C., & Freya, F L (1992) The association of AIDS education and sex education with sexual behavior and condom use among teenage men Family Planning Perspectives, 24(3), 100-107 Lewis, S., & Bor, R (1994) Nurses’ knowledge of and attitudes towards sexuality and the relationship of these with nursing practice Journal of Advanced Nursing, 20, 251-259 Lief, H L., Fullard, W., & Devlin, S J (1990) A new measure of adolescent sexuality: SKAT Journal of Sex Education & Therapy, 16(2), 79-91 Macionis, J J (1995) Sociology (5th ed.; pp 355-365) Englewood Cliffs, NJ: Prentice Hall Matasha, E., & Ntembelea, T (1998) Sexual and reproductive health among primary and secondary school pupils in Mwanza Tanzania AIDS Care, 10(5), 571-581 Minakshi, T (1997) Sexual attitudes and behaviors of school students (Grades 6-12) in India Journal of Sex Research, 34(1), 77-85 Ng, M L., & Lau, M P (1990) Sexual attitudes in the Chinese Archives of Sexual Behavior, 19(1), 373-387 Payne, T (1976) Sexuality of nurses: Correlations of knowledge, attitudes and behavior Nursing Research, 25(4), 286-292 Pleck, J H., Sonenstein, E L., & Ku, L C (1991) Adolescent males’ condom use: Relationships between perceived cost-benefits and consistency Journal of Marriage and the Family, 53, 733-737 Schwartz, I M (1996) Sexuality education, HIV/AIDS education, and contraceptive use during initial coitus as perceived among female college students: A comparison between the United States and Sweden Journal of Health Education, 27(3), 156-161 Shek, D.T.L., & Lam, L.K.H (1985) Mental health education in Hong Kong: A critical review of the formal curriculum Hong Kong Journal of Mental Health, 14, 22-33 Shek, D.T.L., & Mak, J.W.K (1989) Sexual health of high school students in Hong Kong International Journal of Adolescent Medicine and Health, 4(3/4), 175-186 Sue, D (1979) Erotic fantasies of college students during coitus Journal of Sex Research, 15, 299-305 Tang, S K., Lai, D M., & Chung, K H (1997) Assessment of sexual functioning for Chinese college students Archives of Sexual Behavior, 26(1), 79-90 Tompkins, E S (1999) Commentary on “An adolescent and young adult condom perception scale.” Western Journal of Nursing Research, 21(5), 632-633 The University of Hong Kong (1995) Survey on young people’s attitude toward sex and related matters Hong Kong: Author Visser, A P., & Bilsen, P (1994) Effectiveness of sex education provided to adolescents Patient Education and Counseling, 23, 147-160 Downloaded from wjn.sagepub.com at East Tennessee State University on June 20, 2015 March 2001, Vol 23, No 223 Yi, J L (1998) Vietnamese American college students’ knowledge and attitudes toward HIV/AIDS Journal of American College Health, 47(10), 37-43 Downloaded from wjn.sagepub.com at East Tennessee State University on June 20, 2015 ... attitudes in designing effective sex education programs (Pleck, Sonenstein, & Ku, 1991) Educators, sociologists, and psychologists share a common framework, in which education modifies knowledge or... only a minority had attended formal sex education in school Although the Hong Kong Education Department (1986) has advised schools to provide quality sex education programs that cover sensitive... Sexuality education, HIV/AIDS education, and contraceptive use during initial coitus as perceived among female college students: A comparison between the United States and Sweden Journal of Health Education,