Substance use, risky sexual behaviors, and their associations in a Chinese sample of senior high school students

Adolescence/youth is often characterized as a stage of increased imitation and exploration with a range of risky behaviors, including risky sexual behaviors and substance use [1–5]. Previous studies revealed that risky behaviors had the characteristic of clustering in one person [1–3, 5, 6]. For example, risky sexual behaviors (such as multiple sexual partners and unprotect sexual intercourse) among adolescents and youths have been shown to be easy to co-occur with a range of other risky behaviors including alcohol drinking, cigarette smoking, drug use, and violence [1, 2, 6–8]. In turn, substance use and violence have been implicated in increasing the likelihood for participation in risky sexual behaviors [1, 5–7].

A recent report on risky behaviors among American adolescents and youths aged 10–24 years indicated that 4.4% ever had used illicit drugs, 75.0% ever had drunk alcohol, 47.8% ever had sexual intercourse, and 38.5% of currently sexually active adolescents/youths had not used a condom [4]. Researches in other countries similarly found a higher prevalence of risky sexual behaviors and substance use in adolescents and youths [5, 7–9]. Given the higher prevalence of risky sexual behaviors and substance use, adolescents and youths aged 15 to 24 years represent approximately 25% of sexually active persons and account for nearly half of new HIV infection each year in the USA [10]. Therefore, adolescents and youths are important subpopulation for sexual-related prevention and intervention efforts.

China is a developing country with a total population of approximately 1.3 billion. Of this 1.3 billion, 24.25% were adolescents and youths aged between 14 and 29 years in 2009 (State statistical bureau of the People’s Republic of China, 2009). With the rapid economic development, sociocultural changes, and globalization, Chinese adolescents and youths are becoming more and more sexually active and easily access to substance use [11–14]. Shangai, the biggest city and metropolises in China, attracts many people of other districts and even other countries to settle and is labeled as a migration city. The ongoing social, cultural, value, and belief mixing may promote the upward trend of exposure to risk behaviors and substance use in adolescents and youths.

Despite its importance, however, to the best of our knowledge, there are only a few researches on risky behaviors in Chinese adolescents/youths. For example, several reports demonstrated that the prevalence of lifetime sexual intercourse was ranged from 1.3% to 4.8% in Chinese senior high school students [11–14]. An earlier survey on drug/psychoactive substance use among adolescents/youths in a south-west province showed the prevalence of substance use were, in rank order, tobacco 4.2%, alcohol 1.6%, NSAID 0.8%, sedative/hypnotic 0.1%, solvents 0.1%, and cannabis 0.1% [15]. A more recent study in Yunnan province found that, among illicit drug user, 64.96% was adolescents and youth (≤18 years, 4.54%, 18–25 years, 60.4%) and 80% of drug users have sexual intercourse experience [16].

During recent years, the growth of the HIV/AIDS epidemic in China is slowing down [17–19]. However, the challenges for HIV/AIDS control are ever bigger than before due to the major shifts in the route of HIV transmission in China: from parenteral to sexual, from high-risk groups to the general population [17–19]. Sexual contact continues to be the major and increasing route of HIV transmission [17–19]. In the context of the efforts to control the transmission of HIV, a full understanding of risky sexual behaviors among general adolescents and youth are of particularly necessary. This necessity is further underscored by the fact that most published studies on risky sexual behaviors mainly focus on high-risk groups. This study filled this knowledge gap by describing the prevalence of sexual risk behavior and substance use engagement by socio-demographic factors among a sample of Chinese high school students. In addition, given unprotected and multiple-partner sexual contact being the most common mode of sexual transmission of HIV infection among adolescents and youth [17–20], we particularly explored the risk factors of ongoing unprotected sexual intercourse and multiple-partner sexual intercourse in the sample.

To the best of our knowledge, this study was the first to examine HIV/STI risk behaviors according to three dimensions- sexual behaviors in lifetime, sexual behaviors in last three months, and substance use behaviors in the last three months- in a large sample of urban Chinese high school students. Moreover, we particularly explored the association of substance use and socio-demographic factors with ongoing unprotect sexual intercourse and multiple-partner sexual intercourse.

Overall, our study demonstrated that the proportions of senior high school students who ever had sexual intercourse in lifetime or during last three months were 7.0% and 5.1%, respectively. A number of previous studies revealed that the prevalence of lifetime sexual intercourse was ranged from 1.3% to 4.8% in Chinese senior high school students [11–14, 22, 23]. In studies of other countries, adolescents who ever had sexual intercourse was 48.7% in the United Sates (aged 10–24 years) [4], 38% in Italy (aged 14–19 years) [24], 17-46% in South African (aged 13–17 years) [25], 11% in Burkina Faso (aged 12–19 years) [26], 18-22% in Nigerian (aged 15–19 years) [27], and 5.1-56.6% in Turkey (aged 16–20 years) [28, 29]. The disparity in the prevalence of sexual intercourse among adolescents of different countries may be due to different sample characteristics, different traditional cultural background, and different socioeconomic environment.

Among sexually experienced adolescents, a higher prevalence of unprotected sexual intercourse (42.4% in lifetime and 42.1% in last three months) was found in this sample of urban Chinese students compared their peers of developed countries [4, 30, 31]. Studies in US, Sweden, and UK showed that unprotected sexual intercourse rate ranged from 14.0% to 38.5% in adolescents [4, 30, 31]. Previous study indicated that knowledge and awareness about HIV/STI were lower in Chinese adolescents, which may partly account for the higher prevalence of unprotected sexual intercourse in our study sample [11, 23]. The present study specially examined the associations between substance use and ongoing unprotected sexual intercourse, where it was shown that substance use, and specifically often/usually cigarette smoking and illicit drug use were strong risk factors for unprotected sexual intercourse, which was in agreement with previous studies [1, 5]. A more recent study particularly examined the relationship between substance use and HIV/STI-related sexual risky behaviors among a national sample of sexually active adolescents in American rural settings, where it was similarly found that smoking could increase the likelihood of unprotected sex [32]. There is increasing evidence that illicit drug use may be a risk factor for unprotected sexual intercourse in adolescents by cross-sectional studies [1, 8]. A quantitative longitudinal design was implemented to assess causal relationship between illicit drug use and risky sexual behaviors in a sample of gay and bisexual men at 4, 8, and 12 months post-baseline, which indicated that illicit drug use could predict subsequent risky sexual behaviors, such as unprotected sex and multiple-partner sex [33].

The results of our study showed that in our sampled adolescents, 1.4% ever had injection drug use, 1.2% ever had oral/rhinal drug use, 2.0% often/usually smoked, and 4.0% often/usually drunk in last three months. A possible interpretation regarding the mechanisms of association between substance use and high-risk sexual behaviors was that substance use can adversely affect adolescents’ decision-making and result to compromised judgment [34]. In addition, problem behavior theory suggested that problem behaviors (including sexual and substance use activities) tended to cluster and co-occur in adolescents, which was associated with adolescents’ personality, behavior, and the perceived environment [35].

Among the adolescents with experience of sexual intercourse in lifetime or during last three months, 39.7% and 49.4% ever had sexual intercourses with two or more sexual partners, respectively, which was obviously higher prevalent and beyond our expectation. To the best of our knowledge, this study was the first to report Chinese adolescents’ risky sexual behaviors, so, it was unavailable to do comparison with other researches in China. Studies in other countries similarly demonstrated that multiple-partner sex was a common practice in sexual active adolescents [28–30, 34–36]. For example, a study in Swiss high school students found that the median number of sexual partners was two in students who had sexual intercourse experience [30]. In the United States, the prevalence of multi-sexual partner was 33.0%-56.0% in adolescents with sexual intercourse experience [36, 37]. In other countries, this rate ranged from 40% to 75.2% [28, 29]. In high-risk adolescent groups, such as delinquent youth and homeless youth, this rate was extraordinarily high and even reached to above 90.0% [34].

The present study found that younger age of first sexual intercourse was related to an increased tendency of ongoing multiple-partner sexual intercourse. In our sampled adolescents with sexual intercourse experience in lifetime, age of first sexual intercourse was distributed as: ≤14 years (16.4%), 15–17 years (49.5%), and ≥18 years (34.4%). Contrast to a few years ago, age of first sexual intercourse in adolescents of Shanghai urban area were much younger [38, 39]. Between 2001 and 2005, the percentage of adolescents who initiated first sexual intercourse <18 years was approximately 20-30% [38, 39]. Previous studies suggested that early sexual experience had adverse impact on later sexual activity [37, 38]. There was evidence that early sexual intercourse was associated with later substance use, inconsistent condemn use, as well as multiple sex partner [40], which supported the finding of our study. Moreover, a more recent study in men who have sex with men (MSM) found that MSM with a history of childhood sex were more likely to report frequent casual partners and therefore more likely to be HIV positive and to engage in unprotect intercourse [41].

Many factors were associated with adolescents’ initiation of sexual intercourse: age, ethnicity, gender, substance use, economic status, and sociocultural tradition [42, 43]. As an Asian country, Chinese society has intrinsic sociocultural values and traditional convention. In Chinese traditional culture, abstain is especially emphasized for unmarried people, especially for females, which is considered to be linked to personal and family honor. However, with the rapid economic development, massive migration, and ongoing acculturation in China, particularly in big Chinese cities (such as Shanghai, Beijing, Guangzhou, and etc.), the traditional conservative value faces challenges. Coming along side an increase in personal freedoms, the spread of the internet, and growing curiosity about overseas norms of behavior, it has contributed to a far more permissive and promiscuous society than was the case in the past. Only a few years ago, the percentage of adolescents who ever had sexual intercourse was ranged from 1.3% to 4.8% in high school students of Beijing, Shanghai, and Guangzhou [11–14, 22, 23]. Compared to their peers a few years ago, adolescents in big Chinese cities nowadays seemed to be becoming more and more sexually active, which may lead to an increase of sexual behaviors and a shift to younger age of first sexual intercourse [11–14, 22, 23, 38, 39].

There are several limitations that should be considered in interpreting these results. Firstly, social-desirability bias and inaccuracy may be existed in answering the questionnaires despite guaranteed anonymity. The second limitation existed in study design. The cross-sectional nature of the study precludes inferences on causality. Thirdly, given the cosmopolitan nature of Shanghai in comparison to the rest of the country, and especially compared to rural China, our findings may not reflect the overall practice in China. Finally, our sample limited our analyses of demographic subgroups (senior high school students in urban area of Shanghai) and can not be generalize to other population.

In conclusion, our findings provided information regarding Chinese adolescents’ sexual and substance use behaviors. Compared to their peers of many other countries, Chinese adolescents were in a lower level of prevalence of sexual intercourse, however, some risky sexual behaviors, such as unprotected sex and multiple-partner sex, were were more prevalent among those who are sexually experienced. Taking into account a small proportion of youth in China equaling a very large number, we should not take this finding lightly. In addition, we found that substance use and earlier first sexual intercourse could increase the odds of ongoing unprotected sex and multiple-partner sex, respectively. These results suggested that those adolescents with sexual and substance use behaviors seemed to be problem adolescents. Based on the results, we advocated heightened concerns be target the adolescents, particularly those adolescents with sexual and substance use behaviors. Further research is needed to develop effective interventions for this population to reduce sexual and substance use behaviors, which may have a long beneficial to the control of HIV/STI in China.