Sex education, sex-related knowledge, and proper sexual attitudes are important to protect adolescents from risky sexual behaviors, unintended pregnancies, and other adverse health outcomes.[3, 5, 7, 8] In this study, we used a questionnaire to evaluate Chinese high school students’ characteristics, sex education experiences, needs, knowledge, and sexual attitudes. Our results revealed that girls tended to have higher level of sexual knowledge and more positive attitudes towards puberty troubles. However, girls received more attention from parents/school regarding sex. The gender differences in students’ sexual knowledge and attitudes may partly be explained by their needs for knowledge and education from parents/teachers.
Our results showed that Chinese high school students got a relatively low level of sex-related knowledge, but they did not have adequate sexuality education. One third of the respondents believed that “safe period” and “external ejaculation” were effective contraception methods, and about half of them cannot recognize all the AIDS transmitted routes. Our results were consistent with other research that adolescents lacked sex-related knowledge in China.[9, 15] and in western countries. However, only 20–30% of respondents obtained knowledge about contraception/STD from parents and school in our study (Supplemental Fig. 1b). These findings indicated that the respondents, their parents, and school focused more on knowledge about physical changes and sexual health, while neglect the importance of knowledge about STD and contraception. Sexual conservatism tradition in China makes parents and teachers difficult to discuss sexual issues openly with adolescents, and prefer abstinence education strategy rather than comprehensive sexuality education.[5, 15] which may lead to adolescents’ lack of knowledge about contraception, pregnancy, and HIV. As education from parents/school was identified as an independent factor of respondents’ knowledge score in our study and other research.[5, 9, 11, 15, 17] more training should be provided to both parents and school, and encourage them to take comprehensive sexuality education that cover knowledge about contraception, pregnancy, STD, and intimate violence.
Gender differences were noticed in sex-related knowledge and sex education experiences in our study. About 20% of boys did not know the reason of pregnancy, while the percentage of girls was only 4%. Other knowledge items showed similar trends, which was consistent with other research.[17, 18] Accordingly, we found that parents and school were more likely to provide sex education to girls, and girls learned more about sex from parents and school (Supplemental Fig. 1). Boys relied more on video, magazines, and the Internet to obtain sexual knowledge. Therefore, boys may be a neglected group for sex education in China. Some research found that a quarter of parents considered boys were not likely to be sexually abused.[12, 19] and only provided abstinence education rather than comprehensive sexuality education. The lack of formal education make boys to look for other sources, such as peers, the Internet, and pornography, to learn about sex.[11, 20] Without proper guidance, boys may be more likely to be involved in risky sex behaviors, early sex debut, and multiple partners.[6, 10, 11] and lack related knowledge to protect themselves.
Moreover, we found that Chinese adolescents did not have much need for sexuality education, which may be a potential barrier for them to acquire important sex-related knowledge. Although 89% of respondents believed that sex education was necessary, most of them would like to learn topics such as physical and physiological changes during puberty, while less than 20% realized the importance of prevention of STD, intimate violence, and contraception methods (Supplemental Table 3). These results were consistent with the lack of knowledge of contraception, pregnancy, and HIV in our study. Most of the respondents believed that junior high school (age 13 to 15) would be the best time for initiation of sexual education, which was later than other countries.[21, 22] The above results indicated that Chinese high school students got low needs for sex education, indicating the importance to improve their attitudes and inspire their motivations of learning. We calculated their need score of sex education, and found that knowledge source score and knowledge from parents/teachers were independent predictors. Our results were in accordance with other research,[21, 23] and indicated that more sources and more education from parents/teachers should be provided to improve students’ self-perceived needs of learning sex-related knowledge.
We also found gender differences in attitudes in several situations. Girls were more likely to perform positive behaviors when they encounter troubles about puberty, and this gender difference remained significant in the adjusted model. Possible reasons may be that girls were considered to be more vulnerable to sexual harassment or STD, and they received more attention from parents/teachers, which may give girls a closer feeling for consultation. Apart from gender, we found that parents’ detailed answers to children’s questions would increase their likelihood of having positive coping styles. Other studies found similar results, and revealed that high quality of parent-child communication can improve behavior outcome and reduce unintended pregnancy among adolescents. For the attitudes towards discussions about adolescence, although girls tended to be more positive than boys, this difference was not significant in the adjusted model. Need score was identified as a positive factor, indicating that adolescents with more need for related knowledge would take a more positive attitude with discussions among peers.
Recently, an ecological system of adolescent health risky behaviors was developed to explain the interactions between behaviors, people, and their environment.[11, 25] We observed some gender differences in sex-related knowledge and attitudes, and found that these differences can be partly explained by adolescents’ experiences, education, and cognition. These results had some implications for future sex education. First, comprehensive sexuality education, including knowledge about contraception, pregnancy, STD, and intimate violence, may improve adolescents’ knowledge in these fields. Second, communications among adolescents, parents, and teachers about sex are important ways to influence teenagers’ knowledge, attitude, and behaviors. Adequate training for parents and teachers may help them increase their own knowledge and facilitate communications with adolescents.[15, 26] Third, boys may be a neglected group for sex education in China. They should be provided with more education and guidance regarding sex. Targeted sex education, including pre-education survey for screening target teenagers, defining needs of information, and designation of specific lecture, may be effective methods to improve adolescents’ knowledge, attitude, and health outcome.
Our study had several limitations. First, we can only identify the correlations among variables rather than casual effects with the cross-sectional design in the present study. Second, our results need to be interpreted with caution as the convenience sampling used here, and the conclusions may not be generalized to all Chinese adolescents. National probability samples of high school students may be used to examine the gender differences in future studies. Third, we only asked about biological sex in this study, and the sexual education and knowledge remained unclear among sexual and gender minority in China. More research is needed to investigate sex-related education, knowledge, and attitudes of sexual and gender minority in the future. Forth, self-reported questions may be influenced by recall bias, and objective biological outcomes may be used in future studies.