Assessment of knowledge, attitude, and practice of sexual health among students in a Chinese medical college: a cross-sectional study

Abstract

Background

Sexual health is an essential part of overall well-being, and medical students’ sexual education, level of sexual knowledge, and attitudes toward sexual health will affect their sexual behavior.

Aim

To explore the correlation among medical decision tendency, sex education level, and sexual health KAP (knowledge, attitudes, and practices).

Methods

We conducted a cross-sectional survey in March 2019. Data were collected via online surveys with a self-developed questionnaire covering sexual KAP and sexual education. We used Spearman correlation to assess the effect of sexual education on KAP after scoring the related questions.

Outcomes

Outcomes included descriptive analysis and correlation of medical and nursing students’ KAP and education regarding sexual health.

Results

Medical and nursing students hold a high level of sexual knowledge (74.8%) and a positive attitude toward premarital sex (87.5%) and homosexuality (94.5%). By conducting the correlation analysis, we observed that medical and nursing students’ tendency to support friends’ homosexuality was positively correlated with the view that medical intervention for transgender or gay/lesbian people is unnecessary (P < .01). A positive correlation was also found between medical and nursing students who want more diverse sexual education and who would tend to provide patients with more humanistic care regarding their sexual needs (P < .01).

Clinical Translation

Medical and nursing students who want more diverse sexual education and who had higher scores in the sexual knowledge test tend to provide their patients with more humanistic care regarding sexual needs.

Strengths and Limitations

The research shows the current situation of medical and nursing students’ sexual education experience and preference and sexual knowledge, attitudes, and behavior. Heat maps were used to more intuitively describe the correlation between medical students’ characteristics and their sexual knowledge, attitudes, and behaviors and sex education. The results may not be generalizable across China, as the participants were from 1 medical school.

Conclusion

It is essential to provide sexual education for medical and nursing students to ensure a more humanistic approach to patient care regarding sexual needs; therefore, we recommend that medical schools invest in sexual education for medical and nursing students throughout their education.

Introduction

Sexual health is an essential part of overall well-being related to sexuality.^1-3 This is particularly important for college students who are sexually mature and actively involved in intimacy and sexual contact. However, sexual problems are common among people in their 20s.^4-7 According to the Chinese Center for Disease Control and Prevention, Chinese college students have a high rate of unintended pregnancy, induced abortion, and sexually transmitted diseases (STDs),⁸ as well as an increased risk of HIV transmission.⁹ Consequently, it is very important to understand the sexual knowledge, attitudes, and practices (KAP) among college students. As compared with students in other majors, medical students have a deeper level of sexual knowledge, and their sexual attitudes and behaviors will affect their medical attitudes and behaviors toward patients after becoming doctors.¹⁰ The ability and readiness to talk with patients about sexual problems depend not only on education in sexual physiology and pathology but also on the doctors’ beliefs and attitudes toward sexuality.¹¹ Physician discomfort, embarrassment, and perceived lack of time and/or training all play a role in preventing physicians from discussing sexual health with patients.¹²

Globally, medical education is a rigorous process.¹³ The courses and training for these future health care providers are highly demanding.¹⁴ Moreover, courses in medical college provide professional knowledge about anatomic and physiologic features of sexual behavior, which is likely to influence students’ attitudes toward sexuality¹⁵ and their sexual behaviors. In addition to the relationship between sexuality and personal well-being, a correlation has been reported between medical students’ sexual experience and their clinical practice in handling the sexuality issues of patients.¹³ For instance, discrimination against homosexuality and fear of patients living with HIV/AIDS might impede future doctors and nurses from providing high-quality health care to these individuals.¹⁶ Despite guidelines recommending regular reproductive and sexual health counseling for adolescents, studies have demonstrated that providers seldom engage in such discussions due to discomfort, time constraints, and a lack of training in medical school.^17-19 Some studies show that medical students are less likely to watch adult films to acquire sex-related knowledge and to go out on dates,²⁰ which demonstrates the need to increase knowledge and stimulate positive attitudes among students about sexuality, thereby improving their ability to treat patients with sexuality problems.²¹

Although some previous studies have described the cognition, attitudes, and behavior toward sexuality among medical students, these descriptive studies on medical and nursing students have limited reference value for the revision of their sexual education schemes. Questions remain whether the current sexual education fits medical and nursing students’ needs and what influence may sexual education bring to medical and nursing students once they start a career as a doctor or nurse. Here, our questionnaire provides comprehensive insights into medical and nursing students’ sexual education by covering a range of topics related to education experience and preference, sexual KAP, and their tendencies toward humanistic medical care and LGBTQ people (lesbian, gay, bisexual, transgender, queer).²² After presenting the descriptive statistical results of all the sex-related issues, we utilize correlation analysis to investigate potential factors influencing the future medical practice behaviors of medical and nursing students, which we are concerned about.

Methods

Study design and participants

This cross-sectional study was carried out via an electronic questionnaire at a medical college in Beijing, China. The data were collected in March 2019. A small pilot study was carried out among 12 undergraduate and 12 graduate students (12 males and 12 females) from the MD program, nursing school, and graduate school in a medical college to ensure the accessibility of the questionnaire, readability, and clarity. Approximately 15 minutes was required for respondents to access and complete the questionnaire, and no errors or unclear content was identified. For the full-scale study, we conducted cluster random sampling by randomly selecting classes from the MD program, nursing school, and graduate program and by collecting data during a major class break. We provided the QR code on a projection screen in classrooms and explained the study to all students. Respondents who participated voluntarily completed the electronic questionnaire. To minimize the chance that the participants would complete the survey more than once, only a single survey from 1 Internet protocol address was permitted.

Ethics approval was obtained from the Institutional Review Board of Peking Union Medical College (CAMS&PUMC-ICE-2020-030). Each participant signed an informed consent form before beginning the questionnaire.

Questionnaire construction

A structured electronic questionnaire was designed online with Questionnaire Star (www.wjx.cn) (Figure 1). The questionnaire consisted of 2 sections. The first section collected participants’ basic information, such as age, biological sex, gender identity, marital status, grade and program, birthplace, and sexual orientation. The second section assessed sexual knowledge, sexual attitude, reproductive health behavior, and sexual education experience. Our team conducted reliability and validity of the questionnaire, with Cronbach coefficient α at 0.715.

Sexual knowledge

The sexual knowledge section was based on relevant literature that identified the critical questions that would directly reflect students’ reproductive health.^23,24 The scale consisted of 4 dimensions: reproductive system (6 items; eg, “The hymen is located inside the vagina”), correct contraceptive measures (7 items; eg, “Safe period contraception is an effective contraceptive measure”), determination and prevention of STD (14 items; eg, “Syphilis is a sexually transmitted disease”), and HIV prevention and discrimination prevention (8 items; eg, “HIV can be transmitted by dining with someone who is HIV positive”).

Sexual attitudes

The sexual attitudes section was developed from a pool of items from several available sexual attitude scales, socially controversial sex-related topics, and clinical experience.^25-27 The scale included 7 items across 4 sex dimensions: sexual psychology (2 items: “For which of the following reasons will you choose to have sex?” and “How does your partner’s previous sexual history affect your relationship?”), premarital abstention (1 item: “What do you think about premarital sex?”), abortion (2 items: “What do you think about abortion?” and “What factors would you consider if you chose to undergo an abortion for an unintended pregnancy?”), and homosexuality (2 items: “How would you respond if your friend of the same/different sex came out to you?”).

Reproductive health behavior

The reproductive health behavior section was developed according to several behaviors that the committee experts thought were critical in affecting students’ reproductive health. This section investigated sexual behaviors (3 items: “Have you ever engaged in the following sexual behaviors?” “When did your first penetrative sexual intercourse occur?” and “How many partners have you had sex with?”), contraceptive and protective behaviors (2 items: investigating the type and frequency of such behaviors), emergency contraceptive behaviors (2 items: investigating the frequency of unintended pregnancy and emergency contraceptive use), and health care–seeking behaviors (2 items: “Have you undergone an abortion? How many times?” and “What would you do if you feel physical discomfort after having sex such as itching or rash on the genitalia?”).

Sexual education experience

The sexual education experience section was developed through discussions with students and committee experts. It investigated whether students received professional sexual education, under what circumstances, and when. Students could provide multiple responses regarding ways that they accessed relevant knowledge. Options were sexual education courses in school, medical courses in school, lectures held by organizations, organized peer education, online media, printed media, family members, friends, and other. The content of the sexual education accessed was also recorded (eg, reproductive system structure and reproductive health; prevention of sexual assault, harassment, and violence; prevention of HIV/AIDS and other STDs).

Statistical analysis

Data describing the demographic characteristics of participants are presented as absolute frequencies and proportions. Previous studies have found that the awareness rate of sexual and reproductive health knowledge among Chinese medical and nursing students ranges from 60% to 80%, while the positive sexual attitude rate is between 30% and 70%.^28-30 Consequently, our study determined that anything >70% constitutes a high awareness rate, and a more positive sexual attitude is considered >60%. To improve the accuracy and reliability of statistical inference in quantitative analysis, poststratification weights were applied on the basis of constituent ratios of different majors in total. The weighted proportions and means of responses were compared. To further quantify the correlations among questions, we scored all multiple- and single-choice questions with descriptive options regarding participants’ sexual education experiences and KAP. Specifically, Q36 to Q40 involved multiple correct answers to each question, so each score depended on the percentage of correct answers chosen by the participant. Q4, Q8 to Q10, Q12, Q13, Q15 to Q18, Q24 to Q35, and Q41 to Q48 addressed participants’ preferences. In these questions, the score for each option was set to be unequal to describe answers varying from conservative to open-minded (see Table S1 for detailed scoring standards). The scores were used to draw heat maps to show the quantitative correlations among questions about sexual education experience and KAP.

Analysis of variance was used to assess differences in continuous variables, and the Pearson χ² test or Fisher exact test, as appropriate, was used to compare differences in nonordered categorical variables (ie, gender). The Wilcoxon rank sum test and Kruskal-Wallis test were used for the ordered categorical variables (ie, birthplace). Spearman correlation was used for correlation analysis of the scored questions. A Bonferroni method was used to correct the significance level. An alpha of 0.05 was considered statistically significant. R software version 4.1.0 (R Core Team) was used to conduct correlation analyses and visualization, and other analyses were performed with SPSS Statistics version 26.0 (IBM Corp).

Results

Participants

A total of 472 students participated in this study, from an overall 475 students approached, giving a response rate of 99.3%. The mean age was 20.9 years (SD, 2.00), ranging between 17 and 30 years. Among participants, 330 (69.9%) were female, 133 (28.2%) were male, and 9 (1.9%) were self-reported third gender. In the survey of participants’ relationship status, 311 (65.9%) were single, 161 (34.1%) were in a relationship, and none were married or divorced (Table 1). Constituent ratios of different majors in the Peking Union Medical College were estimated according to the enrollment announcements from the official website (Table 2).

Sexual KAP according to sex

Sexual knowledge

The mean (SD) score of sexual knowledge among participants was 26.92 (3.92; Table 3), and the overall awareness rate was 74.8%. The mean score in each dimension was 4.32 (1.04) for the reproductive system, 5.28 (1.39) for correct contraceptive measures, 11.20 (1.87) for STD prevention, and 6.12 (1.87) for HIV prevention and antidiscrimination. In STD prevention awareness , scores for students who identified as third gender were significantly higher than those for male and female students: 12.22 (1.99) vs 11.46 (1.98) and 11.06 (1.80), respectively (P = .030).

Sexual attitudes

We recorded the attitudes of participants toward the following controversial sexual issues.

The main motivation for sex was “deep affection for the partner” (97.7%), and sexual activity tended to occur when there was a more stable relationship (eg, engagement). Among students, sexual desire was largely considered a normal physiologic function: students who identified as third gender (100.0%) agreed significantly more than male students (79.7%) and female students (72.1%; P = .016).

Only 12.5% of medical and nursing students were against premarital sex, with significantly more female students (15.5%) than male students (5.3%). There was a significant difference among sexes (P < .001). In total, 48.3% of medical and nursing students believed that a history of sexual activity with multiple sex partners would negatively affect their relationship.

In total, 53.6% of students reported feeling that induced abortion is unacceptable, and 40.3% held the opposite view. More female medical and nursing students felt that abortion was unacceptable.

We found that 71.6% of medical and nursing students supported and respected same-sex friends being homosexual, with the percentage of third gender students (88.9%) feeling this way being higher than female students (74.8%) and male students (62.4%). The difference was statistically significant (P < .05). Overall, we found that students’ tolerance for homosexuality (72.7%) was higher than their tolerance for same-sex friends (71.6%).

Sexual activity

Sexual intercourse was reported by 79 participants: 76 (16.1%) vaginal sex and 9 (1.9%) anal sex. Eight (10.1%) participants had their first sexual intercourse in high school, 68 (86.1%) in college, and 3 (3.8%) in graduate school. In terms of the number of sexual partners, 50 (63.3%) reported having sex with 1 person, 13 (16.5%) with 2 people, 9 (11.4%) with 3 people, and 7 (8.9%) with >3 people.

Regarding safety, 61 (77.2%) of the 79 students said that they took safety measures with a high frequency (>75%); 7 (8.9%), a frequency of 51% to 75%; and 11, a frequency ≤50%. Of the 79 students, 4 (5.1%) experienced an unintended pregnancy.

We recorded participants’ preference regarding medical care with physical discomfort after sex. A total of 58 (73.4%) said that they would choose a regular hospital for treatment; 11 (13.9%) would research and take medication on their own; 7 (8.9%) would do nothing; and 3 (3.8%) would seek help from friends or family. No students stated that they would attend a clinic for help.

Correlation analysis about KAP and medical education

Some straightforward correlations were found, following the theory of KAP. The questions in the practice group correlate with one another (Q15, Q17, Q18, Q21; each with P < .0001); these ask about specific behavior in sexual experience: “Q15: What forms of sexual behavior have you experienced?” “Q17: How many people have you been involved with sexually?” “Q18: How often do you take safety measures during sexual activity?” and “Q21: How often do you or your sexual partner take emergency contraception?” There is a significant positive correlation (each with P<0.0001) between the level of sexual experience reflected in the responses to the four practice questions and a more positive attitude towards premarital sex, as obtained from Q8..

Two questions (Q50 and Q43) were designed to find factors that may influence medical and nursing students’ future behavior in health care. A correlation occurred between Q50 (“As a future health care worker, do you think that transgender or gay/lesbian people need psychological intervention?”) and Q12 (“What is your reaction to a same-sex friend ‘coming out’ as bisexual/gay/lesbian?”; P < .05), as well as between Q50 and Q13 (“What is your reaction to an opposite-sex friend ‘coming out’ as bisexual/gay/lesbian?”; P < .01). Q50 shows medical and nursing students’ view for intervention to LGBTQ from the perspective of future clinical health care staff. Q12 and Q13 asked about participants’ attitudes toward LGBTQ friends. The positive correlation may indicate that medical and nursing students with positive attitudes toward their LGBTQ friends will tend to support the opinion that no psychological intervention is required for LGBTQ people. Q43 (more mental support in clinical practice as doctors) was positively correlated with Q42 (need mental care during anal examination as patients; P < .0001), which shows that medical and nursing students would focus on the same details when seeing a doctor themselves and when treating their own patients. As described in the options, avoiding unnecessary body contact and unnecessary large area of skin exposure for a long time, during physical examination. Q42 and Q43 were positively correlated with several questions, and the top 3 were Q35 (prefer more extended and comprehensive sexual education; P < .05), Q36 (know how to efficiently use birth control; P < .05), and Q40 (can identify common misconceptions; P < .05). These correlations may indicate that medical and nursing students who want more diverse sexual education and who received higher scores would tend to provide patients with more humanistic care regarding their sexual needs. The positive correlation between Q13 (support an opposite-sex friend’s homosexuality) and Q43 (P < .05) additionally showed that medical and nursing students with positive attitudes toward their LGBTQ friends would also tend to provide their patients with more humanistic mental care (Figure 2).

Discussion

The main findings of our study include assessment of sexual knowledge, attitudes, and behavior and sexual education as well as differences in subgroups by gender and birthplace. Furthermore, we conducted correlation analysis regarding sexual knowledge, attitudes, behavior, education, and medical decision tendency.

Medical and nursing students were significantly open-minded about premarital sex

Among the study participants, 330 (69.9%) were female, 133 (28.2%) were male, and 9 (1.9%) were self-reported third gender. Students who identify as third gender might experience a greater risk of depression, anxiety, and low self-rated health than heterosexual students; therefore, targeted interventions are needed for this population.²⁶ Only 16.42% of participants reported having premarital sex, which is similar to the sexual behavior of general college students in China in 2012 (18.5%)³¹ and 2015 (18.1%).³² In comparison, 87% of women born in the 1969-1978 period in the United States indicated having premarital sex by 25 years of age.³³ Half of the students with a sexual experience had a sexual relationship with only 1 partner. Premarital sex was considered unacceptable under any circumstances by 12.42% of participants, which is close to the results of a recent study among college students in China (10.0%).^34,35 Premarital sex has become more tolerable in China over the past decade. The proportion of college students who have premarital sex has rapidly increased as compared with 1998 (1.1%).³⁶ The development of sex education, as well as increased exposure to sexual information,³⁷ might account for this change.

Interestingly, significant differences between female and male students were found regarding the level of acceptance about premarital sex and self-reported sexual experience. Males had significantly higher acceptance and fewer restrictions about premarital sex, and a higher percentage self-reported having sexual experience. There was no significant difference regarding negative attitudes toward partners’ sexual history or negative attitudes toward abortion as a solution to an unintended pregnancy.

Medical and nursing students showed high acceptance of homosexuality

Among all participants, 94.5% did not consider homosexuality an “aberration.” In total, 71.37% of students said that they would be supportive if a friend revealed that he or she was homosexual. This proportion is much higher than the results reported in a study³⁸ among general heterosexual college students in China (54.4%) and is higher than the results of a survey conducted among 437 undergraduate and graduate students in Midwestern public universities in the United States (84.7% among nonheterosexuals and 66.9% among heterosexuals).³⁹ We analyzed these groups and predicted that college major and grade might influence the level of homosexuality acceptance. Several previous investigations have supported this and suggest that high acceptance of homosexuality is related to higher education, which promotes multiculturalism, cognitive sophistication, and complex reasoning among students.^38,40,41 However, one study⁴² indicated that completing university education alone is insufficient; specifically, socially engaged practice is essential.⁴³ Medical and nursing training may provide students with more opportunities to learn about homosexual individuals as they meet and provide health care to various patients every day. This may explain the high level of acceptance regarding homosexuality in medical and nursing students. Sexual and gender minority (SGM) individuals experience high rates of harassment and discrimination when seeking health care, which may contribute to substantial health care disparities. However, medical and nursing students are noted to have a poor understanding of the health problems of the SGM population.¹⁷ Therefore, including information about the health care for SGM individuals in medical curricula would be beneficial, such as an introduction to gender identity, sexual orientation, and the health care needs of SGM patients. In this way, health care for SGM individuals would be more targeted and effective.⁴⁴

Overall correlations detected in the questionnaire

We scored questions to quantify their correlations. Examples were found that confirm the logical chain of “knowledge, attitude, and practice.” For instance, strong positive correlations have been observed between the acceptance of premarital sex and the various types of sexual contact, as well as the number of sexual partners, that students have had. Positive correlations were also found between the support to the same/opposite-sex friends’ homosexuality and the view of unnecessary psychological intervention to transgender or gay/lesbian people as a future health care worker. This suggests that good sex education and guidance are profoundly influential for medical and nursing students as future health care providers, when they encounter their first same-sex friend in their lives.

The positive correlation between “What aspects do you want your doctor to pay attention to?” and “What will you pay attention to when you are a doctor?” showed that medical and nursing students would focus on the same details when seeing a doctor themselves as when treating their own patients. So perhaps incorporating role-playing scenarios into sex education could help medical and nursing students better understand the concepts of sexual health and behavior and apply this knowledge more effectively in their work. For example, when medical and nursing students learn about the prevention and treatment of STDs, they can personally experience what it is like to be a member of a sexual minority group. This will help them to understand the concerns and embarrassment that patients may feel during medical visits and examinations and to adjust their medical service behaviors accordingly.

We found that preference for diverse sexual education and higher scores in the sexual knowledge test were positively correlated with providing patients with more humanistic care.^45,46 To sum, it was suggested that more courses in sexual health are needed at medical schools to address patients’ sexual health–related issues.^47-49

Strengths and limitations

The research explored the characteristics of medical and nursing students on sexual education level and sexual knowledge, attitudes, and behavior. We utilized the Spearman correlation to identify the factors that influence medical and nursing students’ medical practice. To adjust the imbalanced grade distribution, we applied poststratification adjustment to the total sample of 472 students. Still, the limitation of this study is that the results may not be generalizable across China, as the participants were from 1 medical school and our sample size was small.

Conclusion

Our findings indicated that medical and nursing students hold a high level of sexual knowledge and a positive attitude toward sexual behavior. The support to LGBTQ friends was positively correlated with the view of unnecessary intervention for LGBTQ people. Higher requirements as patients, better sexual knowledge, and higher interest on sexual issues were positively correlated with providing patients with more humanistic care. So, adding diverse sexual topics and scenario simulation to medical education would be an important step to promote diversity, equity, and inclusion in medical education and medical practice.

Author contributions

T.L. conceptualized the study. J.Z. and Y.L. analyzed the data and revised the work. X.W., Z.W., and S.Y. collected the data and revised the work. T.L. and J.Z. designed the project and revised the work. All authors read and approved the final manuscript.

Funding

This work was supported by grants from the Chinese Academy of Medical Sciences & Peking Union Medical College (grant 2017zlgc0114) and the Chinese Academy of Medical Sciences Innovation Fund for Medical Sciences (grant 2021-I2M-1-046).

Conflicts of interest: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

References

Author notes