Sex, lies, and videos in rural China: a qualitative study of women's sexual debut and risky sexual behavior.

Many studies document the new liberal attitude toward sexual behavior that has emerged among young people in China following China's opening to international markets in the early 1980s (Higgins, Zheng, Liu, & Sun, 2002; Zhang, Li, Li, & Beck, 1999). As the average age at first marriage among Chinese youth has increased and the average age at first intercourse has decreased, Chinese youth are spending longer periods of their lives being sexually active while single (Gao, Tu, & Lou, 2003; Li, 2000). As a correlate of this recent trend, increasingly more Chinese youth engage in sexual behaviors that place them at risk of unwanted pregnancies, sexually transmitted diseases (STDs), and reproductive tract infections (RTIs; Cao, Wang, Wen, & Cao, 2000; Xu, 1998). Since the traditional focus of sex education programs in China has been on married couples, unmarried Chinese women and, in particular, those in rural settings may have little understanding of STDs and RTIs. In rural areas where distances to medical facilities are greater and women are less educated, RTI rates are notably high, with up to 60% of rural women suffering from RTIs in some villages (UNAIDS, 2002).

Changing Norms in Rural China

Unique cultural norms in operation in rural parts of China have made it easier for young couples to engage in premarital sex there (Merli & Smith, 2002; Yan, 2003). The population movement from rural to urban areas has notably affected traditional culture in rural China. Combined with the decline of the traditional extended family, rural China, like urban China, is experiencing the loss of social control over the younger generation at a time in which more liberal attitudes toward sexual behavior have promoted increased premarital sex (Higgins et al., 2002). In rural China, as elsewhere across China, premarital sex was an absolute social taboo prior to the 1970s. Beginning in the 1970s, a new social practice among young, engaged, rural couples emerged that opened the door to premarital sex. It then became customary for young, soon-to-be-married couples to travel to nearby cities to pose for engagement photos and to make the requisite purchases in preparation for their new households. Young couples usually stayed in hotels for days without supervision, free to experiment with sexual activity prior to their wedding night (Yan, 2003). This practice represents a radical change from the 1950s and 1960s, when young couples were only allowed to visit each other a few times before their wedding day and only under the watchful eyes of their elders. Part of this normative shift may be a response to legal restrictions mandating the minimum age at marriage (Luo, Wu, Chen,& Li, 1999). Since the 1990s, sexual liberties have continued to expand, and most young, rural couples are now free to engage in premarital sex at home, provided the young couple is engaged. However, even the notion of "engagement" has shifted. Young couples may declare themselves to be "engaged" after only short dating stints, and it is not uncommon for young people to break off and enter into new "engagements" many times before finally marrying (Gil, 1994).

Lack of Contraceptive Knowledge

Studies addressing sexual knowledge, attitudes, and practices of young people in China have shown that Chinese adolescents lack basic sex and contraceptive knowledge and self-protection skills (Zhang et HI., 1999; Zhang, 1997). Prior to the 1980s, contraceptive information was only provided to married women, and sex education was largely limited to official government pamphlets. After 1985, the year in which the Chinese government confirmed the first case of HIV, sex education began to receive strong state support and became part of the curriculum offered to adolescents in high schools in urban areas. Impeded by social norms on sexuality, sex education programs focused too narrowly on physiological and psychological development and provided little information on contraceptive use (Zhang et al.; Zhang). The Chinese government has launched massive information campaigns to alter sexual behavior and to contain the spread of AIDS. The persistent view that too much sex education encourages promiscuity continues to hamper improvements to such campaigns (Higgins et al., 2002).

Studies examining the sexual behavior of students in urban areas show that safe sex practices (e.g., condom-protected intercourse) are largely uncommon (Wong & Tang, 2001). In rural settings, educational levels are lower, as is contraceptive use. Consequently, unmarried women in rural areas are even less familiar with the health risks associated with unprotected intercourse than their urban counterparts and have much higher rates of unwanted pregnancies and induced abortions relative to those living in urban areas (Tu, Lou, Tao, & Gao, 1998). According to one survey, 17% of Chinese citizens had never heard of HIV/AIDS, and 77% did not know that condom use can prevent its transmission (AVERT, 2004). Lower literacy rates and higher school dropout rates exasperate this lack of knowledge and skills among rural women and suggest the policy prudence of focusing on rural populations. Over 70 percent of the Chinese population lives in rural areas and, as recently demonstrated, rural areas have the highest HIV infection rates (National Intelligence Council, 2002).

Pornographic Materials

China's increased openness to Western culture has resulted in the influx of pornographic videos, books, and magazines, whose consumers include young and old alike. While this trend has been examined recently (Li, Li, Zhang, & Wang, 1999; Wang, Huang, & Wang, 2000), quantifying the availability and increased consumption of pornographic materials is not the same as knowing how Chinese youth use or make sense of this form of media. Pornography and other forms of mass media becoming increasingly available to Chinese youth constitute a "tool kit" of sexual scripts that youth may consult to navigate their emerging sexuality (Steele, 1999). The influx of pornography in Chinese markets, combined with low levels of education and less effective sex education programs in rural areas, increases the chances that unknowing adolescents will engage in risky sexual behaviors. According to one study, 70% of students learn about sex mostly from books and magazines, while only 7% gain knowledge from school sex education classes (Zheng, 1997). Easy-to-read and possibly more entertaining, pornographic materials easily fill the vacuum in accurate and practical information on sex and sexual hygiene in rural settings where literacy rates and educational levels are lower.

Research Questions

As part of a World Health Organization (WHO)-sponsored sex education project, we applied qualitative research methods to gather information on sexual initiation, risky sexual behaviors, and reproductive health problems among unmarried women, as well as related social norms and traditional customs. Specifically, this study addressed the following questions:

* What are the main reasons that young unmarried Chinese women first engage in premarital sexual intercourse?

* What forms of birth control do they use and what are the determinants of their use?

* How aware are sexually active women in rural parts of China about their fertility and risk of STDs and RTIs?

* What reproductive health problems have they had?

We combined the use of in-depth interviews and focus group discussions to explore personal behavioral patterns and cognitive justifications and to identify norms, attitudes, and general observations regarding sexual behavior and reproductive choices.

METHOD

Study Site and Research Participants

The research presented here draws on a convenience sample of 40 women aged 17 to 23 living in two townships in a rural district southwest of Shanghai (District A). We selected the two townships because they each have a well-organized family planning network that was willing to cooperate with researchers in this study. In addition, both townships have relatively stable populations and are comparable in socioeconomic characteristics, geographic features, and social customs. District A is located 25 miles outside of downtown Shanghai and, according to the Shanghai Fifth Annual Population Census, has a population of 500,000 people. Of these, 67% register their household as agricultural, but most actually work in non-agricultural occupations. The majority of the population has a primary or high school-level education, and about 7% of the population is illiterate or semi-illiterate.

Because of the difficulty of identifying sexually active women, we drew on a convenience sample of women who had experienced an unwanted pregnancy and terminated that pregnancy. We hoped this sample of women would have particularly rich information on premarital sexual behaviors. The women who were recruited to participate in the in-depth interview came from one of two possible samples. First, family planning workers of the two townships agreed to contact and invite the 20 women who we knew had experienced induced abortion sometime in the previous three years based on the WHO baseline survey to participate in this study. Second, over a 12-month period beginning in December 2000, family planning workers identified on a rolling basis 22 additional women who had undergone induced abortion. Family planning workers introduced the 42 women to the interviewers (the first author and two research assistants) only after they had agreed to participate in the study. All 42 interviewees (including the two who later declined to participate) were paid the equivalent of US $10 for their participation. Most of the women participating in the study had a high school education, and one fourth had a technical school degree.

To facilitate the interpretation of the findings gained through the in-depth interviews, we conducted six focus group discussions with 43 sexually active men and women between the ages of 16 and 23 years old. Family planning workers in the two townships identified sexually active young people in their villages and invited them to participate in the focus groups. Each focus group was made up of six to eight participants. Three of the six focus groups consisted only of young men, and the remaining three consisted only of young women. The discussions focused on premarital sexual activity, general sociocultural issues, traditional customs, and reproductive health problems among young people. The interviewers conducting the focus groups did not gather information about the sexual behaviors of the focus group participants themselves, but rather, on behaviors that participants knew to be true of their social groups. Participants were paid the equivalent of US $3.00 for their participation.

Interview Methods

The study protocol received prior approval from the Scientific and Ethical Review Group (SERG), Department of Reproductive Health and Research, WHO. For the individual in-depth interviews, interviewers scheduled times convenient for the women who agreed to participate after informing them that the interview would be primarily about their premarital sex activity, contraceptive use, and reproductive health problems. The interviewers informed the women that the interviews were anonymous and that their responses would be kept confidential. Prior to being interviewed, each of the 40 women signed a consent form. Twenty-five interviews were conducted by the lead author, and 15 with the help of two Chinese research assistants. All interviews took place in the counseling rooms of the townships' family planning clinics. Each interview opened with a few warm-up questions about the women's work and family, followed by questions about her background and social networks. The interviewer then asked a number of open-ended questions about her first sexual intercourse and subsequent sexual behaviors. All women were asked the same core set of questions, but not all questions were asked in the same order. While the women were encouraged to speak freely, care was taken to ensure that every interview solicited information about the same categories of women's sexual histories. The interviews took between 90 and 120 minutes.

All interviews and focus group discussions were professionally transcribed, yielding over 100 pages of transcripts in Chinese. No audiotape recording was used, so transcripts are based on the interviewers' field notes alone. The first author and one research assistant reviewed the transcripts and coded them independently in several stages. First, the two coders located specific segments that dealt with the focal domains addressed in the interview guide (i.e., sexual negotiation skills, sexual initiation, contraceptive use, and reproductive health problems). They identified additional emergent themes (i.e., parents' influence on sexual initiation, pornographic consumption habits) during this process as well. Second, the two coders compared notes, identified discrepancies, and resolved them by discussion. Finally, relevant portions of the interviews were extracted and translated into English by the two authors. All participants were assigned pseudonyms to maintain confidentiality.

RESULTS

Sexual Debut

Most of the young Chinese women taking part in the in-depth interviews were unprepared for their first sexual encounter and, as a result, engaged in unprotected sex. Women's sexual debut typically occurred between the ages of 17 and 20. Most of the women (35 of the 40) indicated that their first sexual encounter took place in the privacy of their parents' or their boyfriends' parents' homes. The event was usually one of mutual consent; 28 women said that both they and their partners had been equally willing. Three women reported that their first intercourse had been forced. Despite mutual consent, one third said that they regretted having had first intercourse at that time, and 33 of 40 reported that their sexual debut had been unplanned. In the interviews, many women expressed regret, stating that they had lost their virginity to someone who did not deserve it.

Our interviews revealed that there were expected as well as unexpected reasons for young women to engage in sex for the first time. Among the expected reasons were curiosity and women's desire to prove their love to their boyfriends. Unexpected was the important role that pornographic videos and parents played in encouraging sexual initiation. While unexpected, the results on pornographic videos are hardly surprising. In contrast, many parents, and in particular, mothers, played a surprising role by encouraging or at least discretely ignoring their children's premarital sexual activities.

Pornographic videos and sexual debut. To gain information on the opposite sex and sexual intercourse more specifically, many Chinese women turned to pornographic magazines and videos. Pornographic films represent an increasingly popular form of entertainment among Chinese youth living in rural settings. Young women in this study stated that they frequently viewed pornographic videos in the company of their boyfriends and were then eager to "try out" what they had observed. Most (33 of the 40) of the women indicated that they either viewed pornographic videos or read pornographic magazines with classmates, friends, or boyfriends. Viewing was often followed by sexual experimentation. During focus group discussions, both male and female participants indicated that pornographic videos were their main source of "sex education." A history of induced abortion was not a prerequisite for focus group participation, speaking for the more widespread nature of this practice. "Zhang," a 20-year-old unemployed women with a high school education, reported,

   I started to watch porn magazines and videos when I was 15 ...
   After seeing these movies, I started thinking more and more about
   sex ... and started to imagine what sexual intercourse would feel
   like ... When I was 15 and in the second year of junior high
   school, I met a young businessman who was 20 years old. He was
   a tenant in my house. We dated for a month, and then, one night
   after we watched a porn video, we had sex, and that was my first
   time.

"Cui," a 21-year-old quality examiner with a polytechnical degree, reported a similar experience, watching her first pornographic video at age 15:

   I found a [pornographic] video in my home, which I guess my
   parents watched. It had a lot of pornographic scenes of sexual
   intercourse. I couldn't help but watch it and then finally I turned
   it off. Since I had a boyfriend, we started watching porn videos
   together. I had my first intercourse after we finished a porn video
   in my room.... Since then, we watch porn videos 2 to 3 times
   every month. They have scenes of oral sex, anal sex and sexual
   intercourse with several partners at a time. After the video, we
   usually have sex. We actually learned different positions from the
   videos and have tried them out during sexual intercourse to
   achieve full pleasure.

Pornographic videos also set the scene for sexual encounters between "Gao," a 19-year-old blue-collar worker in an electronic factory, and her boyfriend:

   My boyfriend borrowed porn videos from his friends and we
   watched them together at his room for about 10 times. There were
   scenes with foreigners and Chinese having sex, and two men having
   oral sex and anal sex with one woman.... We usually have
   sex when we watch porn videos. Actually, we like to imitate their
   sexual activities. We like to masturbate each other, have oral sex,
   anal sex, and vaginal sex.

Parents' tacit approval and active encouragement. The in-depth interviews revealed that it was not uncommon for parents to invite their children's boyfriends or girlfriends to stay the night after they have been dating for a certain period of time. Two out of three women stated that their parents or their boyfriend's parents either encouraged or tacitly approved of their first sexual encounter. Regardless of where the first sexual encounter took place, most (35 of the 40) women indicated that they had cohabited with their boyfriend either at their parents' home or in their boyfriend's home sometime thereafter. The remaining five women indicated that they did not cohabit at their parents' or boyfriend's parents' home, but that they regularly and freely engaged in sexual activity at either location with their parents' knowledge, one to three times per week. Interviews with family planning leaders confirmed that it is not uncommon for parents to "push" young couples together by either overtly inviting dating partners to stay overnight or by discreetly turning a "blind eye" away from sexual activity in the home. "Lei," a 23-year-old blue-collar worker with a polytechnic degree, recalled,

   One day, my boyfriend's parents invited me to dinner. It was very
   late when dinner was finished. It was snowing and the weather
   was very cold. His parents asked me to stay at their home
   overnight. I went to my boyfriend's room. Naturally, it happened
   between us. At first, we were very embarrassed to go in the bed,
   and we stayed up very late that night. At midnight, he began to
   encourage me to have sex with him. I worried about pregnancy,
   but since I was in his room all night, it happened naturally.

"Chen's" boyfriend's family also encouraged her to stay overnight after she had only begun dating her boyfriend two weeks earlier. She recalled,

   One day I was visiting him in his home. Suddenly it began to rain
   heavily. His parents asked me to stay, and I agreed. Naturally, I
   had sexual intercourse with my boyfriend. It began with my
   boyfriend touching my breast and my private part. I was really
   stimulated by his heavy petting and I just couldn't help but kiss
   him and touch his private part. We took off our clothes and had
   intimate contact on the sofa.... Finally, we moved to the bed and
   my boyfriend used a condom before he penetrated.... We had sex
   for a second time in my room one week later. My parents had
   asked my boyfriend to stay overnight.

One month later, the young couple began living together alternating between both families' homes.

Many of the young women interviewed provided detailed accounts of how they felt pushed into having sexual intercourse by a parent. The parent could be the boyfriend's mother, but more frequently, it was the young woman's own mother. Nineteen-year-old "Fang," a blue-collar worker at a local electronic company, was 17 at the time of her sexual debut and had began dating her boyfriend only three weeks earlier.

   One day, my boyfriend was visiting me at my house. My mom
   told me to persuade him to stay overnight. I was curious about sex
   and wanted to try sex out. Later it happened naturally. You know,
   all my family was satisfied with my boyfriend. But I felt like I
   bad lost something afterwards. I worried that he only wanted to
   have sex with me, but didn't really love me. I felt he would treat
   me badly in the future because he would think that I am a cheap
   girl.

"Zhai," a 22-year-old blue-collar worker with a technical degree, had a similar experience. She met her boyfriend when she was 19, and six months later she had sexual intercourse with him for the first time.

   One evening, my boyfriend was visiting me in my home. My parents
   asked him to stay overnight. They said, 'It is too late; you
   should stay here for the night.' Initially, I did not agree with my
   parents. But my parents said, 'Let your boyfriend make the
   decision. If he wants to stay, then he can stay. If he does not,
   then he can just go.' Then my boyfriend watched TV in my room, and
   he approached me and touched and fondled me. I could anticipate
   what would happen, so I tried to stop him. But he did not listen to
   me. Later I was obedient to him and it just happened. I was
   hesitating because I thought this was not the right time and we did
   not have a solid relationship at that time.... I worried about
   getting pregnant, and asked him to buy contraceptives. But he said
   that having sex one time couldn't get you pregnant. Two weeks
   later, we started to live together in my room.

Sexual compliance and coercion. Very often women are sexually "compliant" in that they consciously put their boyfriend's sexual desires ahead of their own and willingly engage in unwanted sex. Many of the young Chinese women who were interviewed described how they had felt worried that their boyfriends would waver in their affections if they did not have sex. Women described how sexual intercourse was a sign of their love, of another level of maturity that their relationships had reached, and as a kind of insurance to keep their boyfriends. They seemed to think that their relationship would be solidified once they had sexual intercourse with their boyfriends. "Sun," a 21-year-old seamstress, fell in love with her boyfriend when she was 18, and she had sex with him for the first time at her parent's home after dating him for six months.

   It was like a natural process. My boyfriend started to stay in my
   room overnight after we had been dating for several months. On
   the first night, I felt very embarrassed and we did not have sex.
   On the second night we watched a porn video. We were stimulated
   by the film and my boyfriend wanted to have sex with me. He
   kept saying sweet words to me. Finally, we had sex that night ...
   I liked him and thought we could be a perfect match. I hoped to
   marry him in the future. In addition, I thought the possibility of
   marriage would be improved once I had sex with him.... Several
   days later, we had sex for a second time and then we started to
   live together in my parents home, and sometimes at his
   parents' home.

"Zhao" was not as interested in marriage as Sun at the time she decided to engage in sex for the first time, but felt that sex would improve the relationship.

   I was visiting him at his house that day. We watched television for
   a while. Then we kissed, embraced, and began to get into heavy
   petting. Finally we got into sex--I did not think I would marry
   him at that time. I only thought he had been my boyfriend for half
   a year, it would affect our feelings toward each other if there
   were no sexual relations between us.

"Gong," a 21-year-old blue-collar worker, provided this account:

   Because my boyfriend was not born in Shanghai, my parents
   opposed our relationship. They asked somebody to introduce me
   to a new boyfriend. My boyfriend was worried and thought I
   would leave him. He wanted me to have sex with him to prove I
   loved him. Under this circumstance, I decided to give up my
   virginity to him to express my faithful love.

A few of the young women reported that they had been more forcibly coerced into sexual intercourse, that is, that their boyfriends had used pressure to convince or force them into having sexual contact against their will. At her first sexual encounter, "Huang," a 21-year-old electronics factory worker, felt forced into sex and later regretted the encounter:

   My boyfriend asked me for sex. But I felt conflicted in my own
   mind. On the one hand, I loved him and wanted to have sex with
   him. On the other hand, we had only known each other for three
   weeks, so our relationship was not solid. Finally, he persuaded me
   and forced me a little into sex. After that, we had sexual
   intercourse every two or three days in his room or in my room. We
   maintained our relationship for about a year, and then we broke
   up because of a big difference in our personalities.... Now, I
   think that my first sexual intercourse was too early. I regret
   having given up my virginity to him. It was worthless.

"Shen" had sex for the first time two years previously when she was 18 and also felt unable to refuse her boyfriend's sexual advances.

   At the beginning, I was very shy. But he persuaded me and said
   he would marry me, and I felt having sex did not really matter.
   What is more, he was very strong; I couldn't stop him. After that,
   I told him that I was worried about getting pregnant. He said 'You
   could just have an abortion in the hospital if you get pregnant.'
   His answer made me feel sad. He just thought about his own pleasure
   and did not care much about me.

Contraceptive Use

Discussions with the various focus groups confirmed that sex education courses offered in school clearly do not fill the information void. There was an overwhelming consensus among male and female focus group participants that these courses focus on the physiological aspects of sexual development and do not cover contraceptive choices or dating relationships. Given the dearth of accurate information on safe sex practices, it is not surprising that of the 40 women interviewed, only 11 had taken some precaution to avoid getting pregnant at their sexual debut and that only four had used condoms. Only five of the women interviewed reported the regular use of contraceptives, with condoms used most frequently. Despite being the method of choice, the women used condoms only sporadically. A significant number of women expressed a preference for more traditional methods, such as the withdrawal (17 of 40) and rhythm (9 of 40) methods. In addition, relatively few thought that they were at risk of an unwanted pregnancy, and even fewer considered STDs. Of the 40 women interviewed, 27 indicated that they were not concerned about contracting an STD from their partners. Awareness of safe sex practices seemed to be superficial, and misinformation regarding the risks and consequences of unsafe sex was widespread. Common misconceptions included the notion that a woman cannot get pregnant the first time she has sex and that certain contraceptives cause diseases. Perceptions that condoms reduce pleasure and that the Pill causes freckling or weight gain also contributed to low contraceptive use.

The lack of preparation and inability to negotiate sexual activity and contraceptive use are notable barriers to contraceptive use. Focus group discussions largely confirmed in-depth interviews that for many Chinese youth, getting contraceptives was not as difficult as actually using contraceptives. For most of the interviewees and both male and female focus group participants, condoms were freely available from the local family planning clinics and pharmacies, and also from friends and classmates. Fifteen of the women interviewed stated that their mother had provided them with condoms. Despite the availability of contraceptives, behavior patterns and situational constraints prevented their use. Sexual initiation tended to be unplanned and spontaneous. Sexual encounters thereafter continued without the consistent use of contraceptives, with many young women wanting to please partners who did not want to use contraceptives. Many women only started using contraceptives after they had experienced an induced abortion. The form of birth control most prevalent after an abortion was the Intrauterine Device (IUD). Of the 40 women interviewed, 13 had an IUD installed subsequent to an abortion. While effective in preventing pregnancies, IUDs are largely ineffective in preventing the transmission of STDs and may even contribute to many RTIs.

Cui did not use contraceptives at her first sexual intercourse due to misconceptions about her ability to get pregnant. To please her boyfriend, she used contraceptives irregularly in subsequent sexual encounters, switching between condoms, withdrawal, and the rhythm method. After her abortion, the doctor installed an IUD to prevent future unplanned pregnancies. She explained,

   It happened unexpectedly, and we never thought of using
   contraceptives. Even though we had condoms on hand at the time, we
   did not use them because my boyfriend told me that you couldn't
   get pregnant the first time you have sex.

"Lei's" contraceptive practices were also influenced by misconceptions and false hopes. She did not use any contraceptives at her first sexual intercourse and continued not to use birth control thereafter, even after she began to live together with her boyfriend. She got pregnant after three months of cohabitation. She justified her behavior by arguing,

   In most cases, people do not use contraceptives the first time they
   have sex because it happens unexpectedly. No one will take the
   time to prepare a condom when they are having sex the first time.
   Also, I thought that you could not get pregnant the first time you
   have sex and that you could not be that lucky to get pregnant so
   easily.... My friend told me that using the Pill will make you
   sick, and that using condoms reduces sexual pleasure. Anyway, if I
   were to get pregnant, my boyfriend and I thought we could go to
   the marriage registration office and get married.

But Lei had miscalculated. Both she and her boyfriend were under the legal age to get married. Her parents compelled her to have an abortion, despite a strong desire to carry the baby to term. After the abortion, her doctor installed an IUD and she continued to live with her boyfriend in her parents' house.

Like most of the women interviewed, "Lin," a 22-year-old office worker, did not favor condom use because of how it "felt" and was reluctant to rely on other measures because of possible side effects.

   I've used condoms sometimes. I never use the Pill because they
   have bad side effects like causing freckles in my face and making
   me gain weight. But using condoms makes me feel like there is a
   diaphragm in between. It really affects the feeling.... Sometimes
   I'm cool-headed and ask my boyfriend to use condom when he is
   just about to come.

Sun faced a similar dilemma, not wanting to use condoms because of her boyfriend, but also not wanting to use other methods because of their presumed side effects. She turned to more "creative" methods to prevent a pregnancy. They were ineffective, and she had an induced abortion after living with her boyfriend for about four months.

   I used the Pill for two or three months when I first started dating
   my boyfriend. But my friends told me that contraceptives have
   bad side effects, so I stopped using them and switched to condoms
   and the withdrawal method. However, my boyfriend does not like
   condoms, so we had to use the withdrawal method most of the
   time. Also, my colleagues told me to squat on the toilet bowl
   immediately after sexual intercourse, so that the semen could flow
   out, and this would prevent pregnancy.

In all of the interviews, the critical role that male partners play in determining the use of effective birth control measures was readily apparent. In case after case, condom use was not introduced, and pregnancies ensued due to women's willingness to comply with their boyfriends' desire not to use condoms and due to misconceptions about other forms of birth control.

Consequences of Unsafe Sexual Activity

As a result of unsafe sexual practices, young women not only got pregnant and had induced abortions, but many also developed symptoms of RTIs, such as pelvic and vaginal infections. Over half (22 of the 40) of the women interviewed described symptoms of RTIs, including foul smelling, sticky discharge, spotting, lower abdominal pain, and vaginal itching. Some of these symptoms may have developed as a result of unsafe sexual practices. Young women such as Chen, Lin, and others indicated that they regularly engaged in vaginal and anal sex on the same occasion without taking standard hygiene precautions to prevent the transmission of diseases. Unfortunately, these couples were simply imitating what they had observed in pornographic videos.

Another consequence of unsafe sex was less expected. The installation of the IUD after an abortion appears to be quite common in rural China and is an additional source of discomfort for many of the women interviewed. Despite the widespread use of IUDs, there appears to be very little discussion between doctor and patient about their potential side effects. The women interviewed often described having poor relationships with their gynecologists, many of whom look down on these women for having abortions, making the women feel less free to express their needs and wishes. Many of the women we interviewed complained of excessive bleeding during menstruation and irregular periods, presumably due to the IUDs they had inserted after their abortion. Because of poor communication, however, many of the symptoms went unchecked and untreated, thereby increasing the risk of infertility in the future.

DISCUSSION

In China today, a dramatic shift in sexual behaviors among adolescents coincides with the rapid spread of STDs, including HIV/AIDS. Through in-depth interviews with women living in a rural district near Shanghai who had previously undergone induced abortion, this study focused on sexual initiation among unmarried women, the context of coital and risk-taking behavior, perceptions of risk vulnerability, and the consequences of unsafe sexual activities. The results of this study indicate that unmarried young women in rural China lack negotiation and refusal skills for a truly consensual first sexual encounter. Faced with persuasive boyfriends and well-meaning parents, young women felt that they had no choice but to comply and to engage in sex with their boyfriends, even after only short dating periods. As a result, young women engaging in sex for the first time were not emotionally prepared and very often failed to take measures to prevent pregnancy and STDs/RTIs.

Western pornography often preceded sexual initiation and helped the couple to "loosen up" a bit. Many young women in our study viewed pornographic videos in the company of their boyfriends or classmates to learn about sexual techniques before engaging in sex for the first time. Relying on pornographic materials to gain sex-related knowledge can have detrimental consequences. Watching porn videos with friends often encouraged couples to behave impulsively and to engage in sex without using condoms. Some women imitated risky and unsanitary sexual behaviors viewed in pornographic videos and contracted serious reproductive health problems. In addition, the pornographic videos that these youth viewed often presented highly stylized portrayals of women and men that encouraged coercive sexual practices that demean and dis-empower women.

Most young women we interviewed seemed unconcerned about contracting STDs from their boyfriends. Contraceptives were largely employed to prevent unwanted pregnancies, and the women appeared to have a poor understanding of STDs and RTIs and how to prevent them. The women were largely unaware of the reproductive health risks associated with certain sexual behaviors emulated from the videos. Risky behavior practiced at first intercourse continued at subsequent sexual encounters. Although many of the women interviewed worried about getting pregnant, women's inability to assert their needs and wishes prevented the effective use of contraceptive methods.

The home was the location of sexual debut for the overwhelming majority of unmarried women in the study.

Their subsequent sexual activities also primarily took place in parents' homes. This suggests that parents' attitudes to premarital sex have become more liberal, with many parents tolerating and even encouraging their children's premarital sex and cohabitation in their homes. The large number of women reporting their parents' encouragement of premarital sex was, at first, unsettling, particularly because this behavior contradicts previous research on the positive effect of communication between parents and adolescents on delaying sexual initiation (Clawson & Reese-Weber, 2003; DiClemente et al., 2001; Hutchinson, Jemmott, Jemmott, Braverman, & Fong, 2003) and on the highly conservative sexual attitudes of Asian immigrant parents living in Western countries (Okaszaki, 2002).

We can only speculate as to the reasons for this behavior. Parents who express tacit approval or who actively encourage their children to engage in sexual intercourse in their homes may do so because they face a dilemma surrounding youth sexual behavior. On the one hand, premarital sex has become increasingly common and, given a situation of decreased social control, parents may feel that they cannot stop their children's early sexual behavior. On the other hand, parents worry about the marriage prospects and fertility of their children. Under these circumstances, parents may permit and even encourage their adolescent children to cohabit as a type of "trial marriage" in the hopes that the relationship will stabilize and lead to marriage. From the parents' perspective, this arrangement has the convenience of decreasing the number of their children's sexual partners. It also allows their children to "test" the virility and fertility of their partners to ensure continuation of the family lineage. This attitude was captured in the statements of the young women who were interviewed, most of whom described having been unconcerned about getting pregnant since they had felt that they could simply marry in the event of an "unexpected" pregnancy. This interpretation is corroborated by other research. In their demographic study of birth rates in 192 villages in four rural counties of China, Merli and Raftery (2000) found a high prevalence of births occurring only nine months after marriage. They explain this demographic anomaly by the tendency for pregnancies to be initiated premaritally. Unfortunately, given legal constraints regarding the minimum age for marriage in China, the unmarried young women in our study had little option but to terminate their premarital pregnancies. Even couples that had planned to get married in the event of an "unexpected" pregnancy ended up terminating pregnancies. When cohabiting youths broke up, they often quickly began sexual relations with a new partner. These sexual behaviors do not bode well from a public health perspective.

Limitations

Caution must be exercised in making generalizations from the results of the qualitative interviews since the research draws on a small convenience sample of rural women who have had abortions in China. Most importantly, women who recently had an induced abortion may respond differently to questions about sexual behavior than other rural women without this experience. Our choice of qualitative data-collection methods was based on earlier work that suggested that these issues were too subtle and complicated to be explored adequately using standard survey techniques (Wang, Lou, Shen, Gao, & Tu, 2002). This research does not attempt to determine precise population prevalence of particular attitudes and behaviors, but rather, it attempts to probe them in some depth. We allowed participants to explain matters from their own perspectives by adapting probes to the particular line of conversation rather than using a predetermined format. Nevertheless, the use of data on self-reported behavior may create a source of bias in that participants may exaggerate or under-report the frequency of sexual activity or use of contraceptives in ways they feel are socially desirable. Despite these limitations, the focus groups and key informant interviews largely confirmed findings from the in-depth interviews, corroborating the validity and reliability of the in-depth interviews.

Implications for Interventions

As demonstrated in the sex education literature, effective programs to reduce adolescent pregnancy and to increase effective contraceptive use must first determine the reasons for sexual risk-taking behaviors in order to select the appropriate programs (Kirby, 2002). Among the 40 rural women interviewed as part of this study, there were two basic reasons for unprotected intercourse. First, there was a general lack of knowledge about fertility, basic hygiene, and STD/RTIs. Second, even among those women who had the requisite knowledge, women often felt coerced into having sex and lacked negotiation and refusal skills to prevent unwanted sexual advances and to avoid unprotected sexual intercourse. Not only boyfriends, but also well-meaning parents, placed young women in situations in which unprotected sex was likely. Our study shows what can go wrong. Cohabitation has never been an insurance for marriage, and many cohabiting couples broke up after living together for a brief period. Shortly after breaking up, young couples went their separate ways, forging new sexual relationships. These social behaviors pose new challenges to policymakers concerned with the spread of STDs and HIV in China.

Our results point to the need to design and implement a multi-faceted sex education curriculum. First, sex education courses must address the obvious lack of sex-related knowledge by providing youth with accurate and uncensored information about sexual hygiene, birth control, and STD prevention. Misconceptions and misinformation impair knowledge about pregnancy prevention and STD/RTIs in China, implying an urgent need to launch an immediate information campaign among unmarried Chinese youth. Second, sex education programs must solicit the participation of parents with the aim of increasing parents' sex-related knowledge and motivation to discourage their adolescent children from engaging in unprotected premarital sex. Programs strengthening family communication about sexual issues and behaviors to help prevent adolescent pregnancy, HIV/AIDS, and other STDs should be especially promoted (Lederman & Mian, 2003). Third, sex education courses must address issues of coercion and other pressure tactics that lead young women to engage in sexual intercourse against their will. For example, sex education programs can work to enhance adolescents' negotiation and refusal skills by modeling situations requiring adolescents' decision-making, refusal, and resistance skills. Of course, even the best sex education programs will not alter a basic problem facing all sex educators: how can young men be encouraged to be more sexually responsible in an environment in which there appear to be little to no negative social sanctions for their behavior? A starting point is to demonstrate the increased risk of STDs and HIV infection, which has become a real threat in China, and in particular in rural parts of China where an AIDS epidemic may be looming (National Intelligence Council, 2002; UNAIDS, 2002).

Note. This research was supported by grants from the World Health Organization (WHO) Department of Reproductive Health and Research (project 98289 BSDA). We thank Professors Elizabeth Thomson, Xiaoming Li, Iqbal Shah, and two anonymous reviewers for helpful comments on earlier versions of this paper. Special thanks are extended to Dr. Shuli Yu and Ms. Yan Shen, who participated in interviewing the 40 women and conducting focus group discussions, and to Giovanna Merli for many useful discussions on reproductive policy and sexuality in rural China.

An earlier version of this paper was presented as a poster at the annual meeting of the Population Association of America, Philadelphia, March 31-April 2, 2005.

Manuscript accepted November 8, 2005

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Bo Wang

Wayne State University School of Medicine

Pamela Davidson

George Washington University

Address correspondence to Bo Wang, Pediatric Prevention Research Center, Wayne State University School of Medicine, 4201 Saint Antoine Street, UHC 6-D, Detroit, MI, 48201; e-mail: [e-mail].