Original Research

The Journal of School Nursing

2014, Vol. 30(6) 420-429
Chinese Adolescents’ Attitudes Toward ª The Author(s) 2014
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Sexual Relationships and Premarital Sex: sagepub.com/journalsPermissions.nav

DOI: 10.1177/1059840514520996
jsn.sagepub.com
Implications for Promoting Sexual Health

Yu-Ting Chang, PhD, RN1,

Mark Hayter, PhD, RN, BA, MMedSci, FAAN2,
and Mei-Ling Lin, RN, MSN1

Abstract
This study was designed to explore Taiwanese school students’ attitudes toward sexual relationships and premarital sex. This was
an exploratory descriptive, qualitative study. Focus groups (N ¼ 8) were conducted with 47 adolescents from three high schools in
Taiwan. Transcripts were transcribed and thematically analyzed using Atlas V 5.0. Adolescent attitudes toward sexual relationships
and premarital sexual behavior comprise the following three dimensions: (1) external incentives, (2) the developmental process,
and (3) internal control. External incentives include the normalization of sexual behavior between peers, the desire to feel included
in a group, parental influence, and media influence. The developmental process includes imagining the sexual experience and onset
of sexual activity. Internal control includes the fear of pregnancy, the fear of parental rejection, and the fear of being judged. These
findings can provide a reference for designing future sex education curricula and counseling programs for adolescents.

Keywords
adolescents, sexual relationship, premarital sexual behavior, qualitative study

Introduction for most people. Sex is not openly discussed within the family
(Chang, Hayter, & Lin, 2012). Similarly, within in the educa-
Sexual relationships and the issues they raise have signifi-
tion system, there is an extremely limited amount of time that
cant implications for adolescent health. They are part of nor- focuses on sex education. Due to the lack of information dur-
mal development yet can cause anxiety and stress for young
ing their formative teenage years, young people often rely on
people. The school nurse’s role includes the promotion of
their friends as a source of information regarding sex (Upad-
sexual health and healthy, appropriate relationships
hyay & Hindin, 2006). As the Internet and pornography
(Lightfoot & Bines, 2000). As such, it is important that
are readily accessible to teens, this is yet another source of
school nurses are aware of what young people think and feel
information about sex; unfortunately, it may also prove to
about this topic. Such understanding allows them to develop
be inaccurate (Braun-Courville & Rojas, 2009; Flood, 2009;
effective and empathic responses and strategies in both the
Strasburger, Jordan, & Donnerstein, 2010). An increasing pre-
delivery of sex and relationship education and the individual valence of early sexual activity among adolescents has been
counseling practice. It is important to understand how differ-
witnessed in Taiwan over the past decade (Health Promotion
ent cultural groups may view this emotional topic. There is
Administration, Ministry of Health and Welfare, 2010). The
some work on the views of Western students in relation to
premarital sexual behavior of high school and 5-year college
sexual relationships (Hayter & Harrison, 2008). Currently,
(includes 3 years of high school education and 2 years of
there is a lack of research with respect to adolescents and sex
from a Taiwanese perspective. However, given the preva-
lence of the Asian community throughout the U.S. and Eur- 1
Department of Nursing, Tzu Chi College of Technology, Hualien, Taiwan,
opean school systems, some awareness of this issue exists Republic of China
(Homma, Saewyc, Wong, & Zumbo, 2013). 2
Faculty of Health and Social Care, University of Hull, Hull, United
Kingdom

Background Corresponding Author:

Yu-Ting Chang, PhD, RN, Department of Nursing, Tzu Chi College of
Although Taiwan is experiencing rapid sociological changes, Technology, #880, Sec 2, Chien-Kuo Rd, Hualien 970, Taiwan, Republic of China.
sexual issues essentially remain a ‘‘forbidden topic’’ or taboo Email: [email protected]

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Chang et al. 421

college education) students in Taiwan has increased. Males a source of sexual information, in conjunction with the ease
show increased sexual activity by 4.3% and females by 6% of access to internet pornography, increases the probability
during the time period from 1995 to 2007 (Health Promotion of distortions in sexual behavior (Braun-Courville & Rojas,
Administration, Ministry of Health and Welfare, 2010). 2009; Flood, 2009).
Homma, Saewyc, Wong, and Zumbo (2013) conducted a Sexual relationships are especially intense experiences
study of 4,311 adolescents, Grades 7–12, indicating that less and are an important stage in the development in which peo-
than 10% of East Asian adolescents had had sexual inter- ple learn to establish intimate relationships, especially for
course. Among those who were sexually experienced, most adolescents (Elders, 2007). Due to the rising rates of sexu-
had engaged in high-risk sexual behaviors, including multiple ally transmitted infections, unplanned teenage pregnancies,
sexual partners and noncondom use in the last intercourse. and abortions among young people, sex education is crucial
The percentage of adolescents who reported having sexual in order to address these issues (Kirby, 2006; Kirby, Laris, &
intercourse was more than 20% in Taiwan, which is signifi- Rolleri, 2007). School nurses have a key role to play in teen-
cantly higher than that reported in China and Vietnam in the age sexual health by sharing the sex education role with
same cohort (Zabin et al., 2009). The rate of teen sexual activ- teachers who are less prepared for this area of education
ity in Asia is rising yet remains low compared to the rate in the (Hayter, Piercy, Massey, & Gregory, 2008; Lightfoot &
United States (27–82%; Cavazos-Rehg et al., 2009; Finer, Bines, 2000). The contribution school nurses make to sexual
2010). However, the prevalence of high-risk sexual behaviors education is valued because they are regarded as ‘‘an outsi-
among sexually experienced adolescents who are Asians did der’’ providing specialist knowledge within an environment
not differ from that of their non-Asian peers (Homma et al., conducive to discussing sensitive issues (Cotton et al., 2000,
2013). Early teen sexual activity may lead to both sexually Lightfoot & Bines 2000).
transmitted diseases and unintended pregnancies. Some stud- Despite the importance that Taiwanese adolescents attach
ies have found that pregnant adolescents have increased risks to sexual relationships, research on this topic is extremely
of preterm delivery, low birth weight, and natal mortality limited. Most research on the sexual relationship and pre-
(Chen et al., 2007; Forhan et al., 2009; Kuo et al., 2010). marital sexual behaviors of Taiwanese adolescents has
Friends and classmates are the main resources of sexual focused on psychological determinants of sexual relation-
information for adolescents. Between the ages of 14 and ship and sexual behaviors (Ko, Lee, & Sun, 2008; Ko & Lin,
16, when young people discover that their peers are sexually 2011; Lin, Che, & Yeh, 2008; Yeh, 2012; Yen et al., 2009).
active, there is evidence that they are more likely to be sexu- In these studies, questionnaires were used to collect informa-
ally active themselves by 19 years of age (Upadhyay & Hin- tion about sexual relationships and premarital sexual beha-
din, 2006). A 10% increase in the proportion of close friends vior. Unfortunately, this method fails to reveal the inherent
who are sexually active increase the probability that an indi- complexity of sexual relationships and premarital sexual
vidual will become sexually active by 5%. A 10% increase behavior. A well-designed qualitative study will lead to a
in the number of sexual partners among close friends also better in-depth understanding of this complexity (Carter
increase the number of sexual partners of an individual by et al., 2013). The aim of this study was to explore the views
5% (Ali & Dwyer, 2011). In addition, pornographic media of Taiwanese adolescents toward sexual relationships and
is also an important factor influencing adolescents’ premar- premarital sexual behavior.
ital sexual behavior. Due to the ease of access to the Internet
and the popularity and plethora of methods for young people
Method
to meet and chat online, this has proven to be an increasingly
popular media for starting teenage sexual relationships (Yen, With the aim of exploring students’ attitudes of premarital
Liu, & Ferng, 2009). Wolak, Mitchell, and Finkelhor (2007) sex and sexual relationships, an exploratory, qualitative
conducted a study of 1,500 youth Internet users aged 10 to research design was employed. This design allowed
17 years to assess the effects of pornography in Alexandria, researchers to conduct analysis of participants’ narratives
VA. Forty-two percent of teen Internet users had been and an in-depth exploration (Denzin & Lincoln, 2000). The
exposed to online pornography in the past year. Another study of individuals within a social and cultural environment
study in New York city, NY, focusing on sexually explicit is possible using a qualitative research design (Lincoln &
websites and teenage viewers, showed adolescents who were Guba, 2000). Of particular importance in this study were
exposed to sexually explicit websites were significantly external and internal factors that have significant impact
more likely to have multiple lifetime partners. They had on sexual health.
more than one sexual partner in the last 3 months, used alco-
hol or other substances at last sexual encounter, and had Ethical Considerations
engaged in anal sex (Braun-Courville & Rojas, 2009). Lou’s The research ethics committee of the Buddhist Tzu Chi Gen-
(2011) study of a vocational high school in southern Taiwan eral Hospital approved the study. The study aim was
found that 73% of students had accessed Internet porn in described for the seventh and ninth grade classes. The par-
some media format. Adolescent reliance on their peers as ents of the students were then contacted in written form. The

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422 The Journal of School Nursing 30(6)

Table 1. Demographics of Participants (N ¼ 47). some examples about intimate experiences or premarital
sexual behavior, yours or others, and how do you feel about
Variables n %
those examples?’’ Participants were encouraged to speak
Grade freely and share as many details as they felt comfortable
9th 36 76.6 with. Interview data were transcribed verbatim for analysis
11th 11 23.4 from the tape recorded sessions. Key information and view-
Gender points were recorded in field notes during discussions.
Female 24 51.1
Male 23 48.9
Living status
Living with parents 23 48.9 Data Analysis
Living with single parent 20 42.6 Transcripts were organized, categorized, and analyzed using
Living without parents 4 8.5 Atlas V 5.0 software. Data analysis was guided by the work
Sexual relationship
Hand holding 21 44.7
of Joffe and Yarkley (2004) and Braun and Clarke (2006) for
Kissing 17 36.2 the thematic analysis. Both groups propose that data be ini-
Caressing 8 17.0 tially examined for particular sections that identify a specific
Sexual intercourse 1 2.1 issue or point in the descriptions of the participants’ experi-
ences. The transcript text was reread, categorized, and coded
with consistent labels and thematic analysis was performed.
confidentiality agreement guaranteed that no individual Finally, the key elements of the phenomenon under investi-
would be identifiable in any publication of the data. Codes gation were linked into substantive themes via an iterative
were assigned to participant information on the transcripts. process using the previous categories. The aim of the data
Withdrawal from the study was open to participants at any analysis is to produce a set of themes that are often linked
time. and can explain all aspects and dimensions and depict the
participants’ views, experiences, or attitudes toward the
Participants research topic.
A purposive approach to sampling was employed. Partici-
pants were recruited at three high schools in Eastern Taiwan.
Students were recruited from the 9th and 11th grades. The Rigor
sample consisted of 24 male and 23 female students, aged The following several steps to ensure the trustworthiness of
14 years 9 months to 17 years 11 months; 36 were from the the findings were incorporated: (1) a pilot study to ensure
9th grade and 11 were from the 11th grade. All participants clarity and understanding, (2) involved high school students
had had 4 hr of sex education every semester from elemen- in the study design to clarify the conditions needed for free
tary to high school. All participants knew they could buy and open sharing, and (3) asked participants to verify field
condoms at 7-ELEVEN, supermarkets, or drug stores, but notes, summary comments at the conclusion of each focus
most of them did not. Only one participant had had sexual group (Krueger & Casey, 2000). At the University of
intercourse. The subjects’ demographic characteristics are Taiwan, data analysis was subjected to ‘‘peer review’’ by
presented in Table 1. two qualitative research scholars and nursing faculty
members and to internal review by members of the research
Data Collection team. The work of Lincoln and Guba (1985, 2000) guided the
Participants were divided and assigned to one of eight focus analysis procedure for credibility in this qualitative study.
groups according to gender, age, and familiarity with each
other. Each group of five to seven participants met for one
to three sessions of 45–60 min. This discrepancy in the fre-
Findings
quency of the meetings was based on participants’ ability to Three themes emerged from the data analysis, which reflect
remain focused on the topic of discussion. Of the eight focus the adolescents’ perspective, experiences, and attitudes
groups, one group met three times and the other seven met toward sexual relationships and premarital sexual behavior:
for two rounds of discussions. Focus group discussions were (1) external incentives, (2) the developmental process, and
facilitated using semistructured questions aimed at eliciting (3) internal control. The following sections use extracts from
adolescents’ perspectives of sexual relationships and pre- the data to illustrate the themes in more detail.
marital sexual behavior. Open-ended questions were chosen
based on a review of previous literature. The interview ques- External incentives. This theme comprised a number of linked
tions were as follows: (1) ‘‘Do you agree with premarital subthemes that represent the external influences on the par-
sexual behavior, explain your reasons?’’ (2) ‘‘What are your ticipant’s attitudes and views on sexual relationships and
intimacy boundaries at this time?’’ (3) ‘‘Could you share premarital sex.

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Chang et al. 423

The normalization of sexual behavior between peers. In this The desire to feel included in a group. Recognition within the peer
study, many participant’s had been exposed to peers who group acts to increase an adolescents’ self-confidence.
had been sexually active since the seventh and eighth grades. Adolescents feel a strong need for a sense of belonging within
the peer group. When their friends engage in sex, it becomes a
Girl 3 stated: So many students around me have already had sex. personal question and desire of the youth to engage in the
I heard that mostly in Grade 7. It was my good friend who told same behavior.
me that she had already done it. A couple days later, I went with
her to buy condoms. Then a couple weeks later, we went to buy Girl 5 stated: I will think if my friends have already done it, why
condoms again. So, I know. In Grade 8, I went with my friend to can’t I? It means we have the same experience, so, I can join in
buy a pregnancy test. their discussion.

The sexual behavior within the peer cohort has been gra- For adolescent boys, the peer pressure of the other boys
dually increasing. As such, adolescents no longer consider sharing their experience is very important. If they cannot
sex to be something special or unique. share a similar experience, they may feel that they do not
belong as part of the group. These young boys may suffer a
Girl 2 stated: More and more people in school are having sex, lack of self-esteem, or self-worth, as they are not able to, or
not only that, I also know someone who already had a baby. have not had the opportunity to, have sex. As such, they can-
So, sex seems pretty normal and nothing special to me. not talk about sex as ‘‘one of the guys’’ when in the group.

When male students engage in sexual behavior, they tend Boy 4 stated: If your friend has already done it you will feel you
to discuss their experiences openly within their peer group of are inferior, you cannot join the group. If all of your friends
friends. Young males discussing sex often do so to show off have already done it, and only you haven’t, you will think that
or as a sign of pride. you are not ‘‘cool’’ because you have never done it.

Boy 5 stated: My friend shared his experience with us. But the
rest of us thought he was just showing off. Then he asked: Have Parental influence. Parents may unintentionally provide the
you done it? And the guys just started joking and chatting. Then I role model after which adolescents fashion their attitudes
found out that most of the boys in this group had already had sex. toward premarital sex. Taiwanese parents seldom discuss
sex with their children as sex is considered a taboo subject.
Among the boys who had discussed their sexual behavior, Some who do discuss sex with their offspring may have dif-
some of the participants were disinterested in their friend’s ferent parenting styles and attitudes toward sex. Adolescents
sexual choices and actions. also make observations of their parent’s actions and come to
their own conclusions based on parental past actions. Some
parents may have married early (17–19 years) and others
Boy 12 stated: I said: If you are doing that so young, aren’t you
afraid of making a baby? I don’t want to care about his prob-
may be very accepting of premarital sex. Adolescents may
lems, it’s not my problem. assume that the circumstances and attitudes of their parents
allow them the freedom to engage in sexual activity.
Boy 3 stated: No difference. If they want to talk about it, talk
about it, I don’t care.
Boy 14 stated: My mom told me, she hopes that I get married
early, and then I can do it.
Other participants choose to respond directly to their
peers with subtle put downs. The boy was asked what he felt about premarital sex at
the present time.
Boy 21 stated: I would tell him that he is ‘‘showing off.’’ That
should be private between him and his girlfriend.
Boy 14 stated: I want to try. I want to do an adult thing.
Boy 18 stated: I would tell him, I’m still a virgin. Pure. I don’t
have any STDs. Familial actions and attitudes toward premarital sex are
important factors that influence the attitudes of adolescents
Some boys feel it doesn’t matter at all if they have not had toward sex. Early marriage and previous teen pregnancy of
sex and would rather not know about their peers’ sexual the mother were found to be important determinants toward
experiences. a predisposition and acceptance of premarital sex.

Boy 19 stated: I haven’t had sex, so I don’t have to talk about it. Girl 2 stated: My classmate’s mother gave birth to her when she
But my friends don’t need to talk about it. These kinds of lousy was really young, so she thinks it’s normal to get pregnant and
friends I don’t need. have a baby at the same age.

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424 The Journal of School Nursing 30(6)

Parents still worry that their children will have unpro- Girl 2 stated: I want to experience it, because my friend told me,
tected sex as they cannot control and monitor their children she has had it. So, I want to know if it is really as good as she said.
at all times. As such, they often tell their children to make
sure they bring condoms. As a result, adolescents feel that Adolescent males experience an obvious physical reac-
their parents are condoning premarital sex. tion and they are extremely driven to experience sex with
a girl.
Girl 5 stated: Some of my classmates’ parents will suggest that
their children bring condoms. As a result my classmates will Boy 3 stated: Due to our age, it’s normal that we will have this
think that their parents are in agreement and allow them to have reaction [erection] and the thoughts [sex].
sex if they want. So, I can do whatever I want.
Onset of sexual activity. Dating or pairing off in a relationship
Media influence. Currently, there exists an information explo- allows for adolescents to spend increasing amounts of time
sion due to the presence of the Internet, various media, the ease together. The opportunity for privacy increases along with
of access, and the excessive amount of pornographic material intimate behaviors. If current sexual and societal norms are
available. The Asian educational system focuses on core sub- compared to the previous generation, it is found that virginity
jects and spends very little on sex education. Due to the lack of among females is no longer as greatly prized. In the Asian cul-
support from the educational system and family, adolescents ture, virginity used to be an important characteristic that
who are naturally curious about sex will access the Internet and would greatly influence a woman’s future. Currently, this is
other media to satisfy their curiosity about sex. no longer the attitude that is expressed among teenage
females with regard to virginity. Female adolescents are more
Girl 4 stated: Junior high has a sex education class, but it was
concerned about the possibility of pregnancy than they are
not very useful. They only told us, you can’t have sex. So, to
learn about sex we look in books, search the Internet or watch concerned about losing their virginity. As long as they feel
sex videos. confident that they can protect themselves from an unwanted
pregnancy, they are comfortable engaging in sexual behavior.
Boys are generally more interested in looking up infor-
mation about sex; they will spend more time searching for Girl 4 stated: In my grade [Grade 9] I think caressing is enough.
and watching sex videos. Sex videos are extremely arousing But, sex is okay too, as long as I use birth control.
and increase curiosity among adolescent males.
Male to female peer pressure was also an issue. Young
Boy 5 stated: When we watch the videos we can hear the girls males will attempt to convince their girlfriends to have sex
yelling, so the boys will be curious, is it really like that? even if she rebuffs his early advances. He will attempt again.

Boy 17 stated: Because I watch the media (porn,) I think about it Boy 6 stated: Maybe after 1 or 2 months, and we have some pri-
(sex) a lot more and want to do it (sex). vacy we will caress and then stop. And again, another time, car-
ess, and then stop. I am always ready to have sex though.
The developmental process. Adolescence is a crucial psycholo-
gical stage where young adults learn and experiment with
developing sexual relationships. As young people develop, Internal control. Premarital sex can lead to teen pregnancy and
the issues of sexual activity and relationships becomes a com- sexually transmitted disease. Of these two life-changing fac-
mon topic; the participants in this study demonstrated this. tors, pregnancy is the main concern of adolescents. Preg-
nancy is a significant and serious occurrence for a teenager.
Imagining the sexual experience. During adolescence, there are
many physical and psychological changes for both males The fear of pregnancy. Among the participants in this study,
and females. At this stage, due to physical and hormonal fear of pregnancy was clearly evident.
changes, adolescents become extremely curious about sex.
Girl 4 stated: Pregnancy is the most important factor. I am too
Girl 18 stated: Now that I am in junior high, I find myself being afraid, because if you get pregnant, the whole world knows it!
very attracted to boys. I am really kind of curious about boys’ So, that is the main point.
bodies and how they work.
As there is no 100% birth control method available,
Through the use of pornographic media being shared young women often worry about pregnancy. As a result,
among the female classmates, they are becoming very inter- many choose not to have sex.
ested in sex.
Girl 2 stated: Even though I use birth control, I still worry that I
Girl 3 stated: I want to know what it feels like, but I am scared. can get pregnant. I’d rather not have to worry at all, so I don’t
But, I am still really curious. have sex.

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Chang et al. 425

If an adolescent girl should become pregnant, the stress and relationship. If I were to get pregnant, my parents would charge
pressure of the situation will impact her male partner. my boyfriend.
Boy 5 stated: If I had the situation, where my girlfriend got Girl 4 stated: I am worried that my parents will scold me. But, if
pregnant, I would have a lot of stress. Having children! I would I don’t get pregnant, there is no way for my parents to find out.
have to quit school. I would have no future! I would think like If I were to get pregnant, it’s a definite, they could not accept it.
that, so I will control myself now and not have sex. And I could not accept that my parents know I am pregnant.

For both male and female adolescents, fear of pregnancy The fear of being judged. The majority of teenage girls accept
is the main factor affecting self-control. It was found in dis- the possibility of premarital sex among their peers and for
cussion that if pregnancy were not a potential outcome of themselves. However, due to cultural influence, they tend
sexual relations, most of the participants were willing to to be very quiet and discreet with respect to whom they
engage in sex. reveal their experiences.

Girl 1 stated: I would do it. Girl 1 stated: I think, if you have had sex or are having sex, it is
better to not let others around you know about it. You can do it, but
Girl 2 stated: If I couldn’t get pregnant, I would do it.
don’t let anyone know about it or they will think you are ‘‘easy.’’
Girl 3 stated: I would try it one time.
Due to peer pressure exerted by male adolescents, the
The boys have the same feelings as the girls. desire to experience sex is tempting. However, due to the
external judgment exerted by surrounding adults in authority
Boy 12 stated: There is nothing to worry about or stop me if she and the nonpermissive attitude toward premarital sex, a sig-
can’t get pregnant. So why not just do it? nificant number of male adolescents will choose to abstain.
Boy 14 stated: I would have no pressure if I had the opportunity
to have sex. Nothing to worry about if I don’t have a condom or Boy 12 stated: It can be due to external pressure, some from
not. We can just have sex and no fear. friends and from home, the pressure is greater. If you were
standing on a road and heard some gossip like: Oh, look at him,
Without the fear of pregnancy, adolescents appear to be he’s so young to be a father! That would be bad!
more interested and willing to engage in sex. The fear of
pregnancy and the social and life consequences of having The external incentives of normalization of peer sexual
a child during teenage years strongly influence teenagers’ behavior, inclusion in teen group, parental influence, and
sexual behavior. Many teenagers choose not to engage in media influence strongly affect teenage sexual behavior.
sexual activity due to the fear of the consequences. The internal incentives of fear of pregnancy and being
judged and parental rejection are another behavioral modi-
The fear of parental rejection. The parent–child relationship is fier of teenage sexual activity.
another key factor influencing adolescent attitudes toward
premarital sex. Parents act as role models not only through Discussion
their expectations and rules in their children’s lives but also
Sexual relationships and sexual behavior are a topic of
through their own actions. The fear of parental rejection also
extreme importance to adolescents. Adolescents are influ-
acts to influence male and female adolescents’ choices with
enced by many external factors, sexual desire, and curiosity.
respect to engaging in premarital sex.
The primary inhibitor of sexual activity is fear of pregnancy
for female and male adolescents. Amongadolescents, peer
Boy 17 stated: Because I have had a great relationship with my
approval remains one of the key factors influencing their
mom since I was very young and if she says to do something,
then I will do like she asks. If she says, I don’t want you to choices and behaviors. Nahom et al. (2001) found that male
do that, then, I won’t do that. After I get married, I can do that. adolescents who had had sex assumed that their peers were
also sexually active. Those who were not sexually active
Teenagers are concerned about their parent’s perception assumed that their peers were also not sexually active.
of their actions and behavior. Young people still seek their Adhikari and Tamang (2009) studied 573 young men
parent’s approval; however, most parents are not accepting (85% were 15–24 of age) in Kathmandu, Nepal, with 39%
of sexual behavior by their children. The primary concern of respondents reporting that they have had premarital sex.
of sexually active adolescents remains the fear of pregnancy. Young adults (20 years old) who have close unmarried
If a pregnancy occurs, it is not possible to hide the conse- friends and engage in premarital sexual intercourse were
quences of sexual activity from the family. eight times (odds ratio ¼ 8.4) more likely to be sexually
active compared to those who did not have such sexually
Girl 28 stated: My parents would be ashamed of me if they knew active friends. Buhi and Goodson’s (2007) systematic
about my behavior. If they knew, it would change our review of 69 research papers, focusing on adolescent sexual

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426 The Journal of School Nursing 30(6)

behavior, found that young males often bragged about and pressure in the form of disinterest or possible termination
exaggerated their sexual experiences. Male reputation among of friendships with other male adolescents may reduce the
his peers is affected by ideas and concepts of sexual prowess interest in pursuing sexual activity.
and conquest. A male who is single and possibly a virgin may The present study shows that the main fear of adolescents
experience a negative effect on his reputation within the engaging in premarital sex is pregnancy. An American study
group dynamic. Teenage approval and peer pressure are key shows adolescents aged 15–19 years have the highest unin-
factors influencing adolescent’s behavior and potential to tended pregnancy rate (Finer, 2010). Due to the high rate of
engage in sexual activity. The results in the present study are unintended teen pregnancy, it is necessary to educate teen-
in accordance with the previous research on adolescent agers with respect to self-control as well as methods of birth
sexuality. control. In Asian cultures, parents hold traditional views of
The current study suggests that the influences of porno- sex. As a result, teen mothers do not receive parental support
graphic media and teenage sexual desire or curiosity are cor- and further it is considered a shame to the family. The teen
related. Lo and Wei (2005) surveyed 2001 Taiwanese mother in an Asian culture experiences great difficulties due
students from 20 randomly selected high schools and middle to her physical condition of pregnancy as well as the lack of
schools and indicated that 38% had exposure to Internet por- psychological and emotional support. In order to reduce the
nography. Teenagers exposed to Internet pornography teen pregnancy rate, it is essential to educate adolescents
showed greater acceptance and sexual permissiveness and about abstinence and birth control.
were more likely to engage in sexually permissive behavior. It requires a skilled and knowledgeable individual to con-
Brown and L’ Engle (2009) conducted a longitudinal study duct reproductive health education in schools. School nurses
of 967 seventh and eighth grade students in the southeastern possess the most accurate knowledge about sexual health and
United States; they showed that 66% of males and 39% of are in the best position to assume the responsibility for pro-
females had seen at least one form of sexually explicit media moting sexual health in schools (Jou, Chen, Lee, & Yin,
in the past year. Longitudinal analyses showed that early 2003; Wang, Chen, & Li, 2012). It is proposed that school
exposure for teenage participants predicted less progressive nurses are therefore best placed to deliver sexual education
gender role attitudes and having oral sex and sexual inter- and to be inclusive of teenagers in this education (Hayter
course 2 years later. The influence of pornography on the et al., 2008). School nurses must recognize and challenge ado-
sexual behavior of teenagers and their sexual relationship- lescents’ attitudes toward premarital sexual behavior and
building skills cannot be underestimated. The prevalence address their lack of knowledge in the school setting (Kirby
and forms of alternative sexual practices may influence the et al., 2007). The teenagers in this study demonstrated a lack
interrelations and sexual practices of teenagers (Brown & of knowledge about broader sexual health as well as control-
L’ Engle, 2009; Flood, 2009; Strasburger et al., 2010). ling sexual desire and sexually transmitted diseases. Teaching
Nahom et al. (2001) conducted a longitudinal study of teenagers how to respond to friends’ sexual activity, recog-
1,174 adolescent males, Grades 8 to 10 in the Pacific North- nize pornographic media, and connect sexual behavior with
west, United States, and found that boys were significantly sexually transmitted disease remains a challenging task.
more likely to intend to have sex than were girls. Upadhyay, Incorporating these aspects in the general sexual education
Hindin, and Gultiano’s (2006) longitudinal data from 1998 approach offers a potentially effective manner to proceed.
to 2000, 2002 survey of 2,051 adolescents aged 17 to 19 The current Taiwan sex education programs are
years in Cebu, Philippines, found that males have a greater designed by the Guidance and Counseling Office and
intention to engage in sex than females. Young males in gen- taught by the Chief of Environmental Section officers and
eral would prefer that the relationship move more rapidly to health care subject teacher. In Taiwan, nurses are not leg-
physical intimacy than the females. The large sample size ally allowed to teach within the school system (Wang
and the scope of the Philippines study illustrate similar find- et al., 2012). At present, they may teach sex education
ings in this study. This may be due to the Asian cultural within the classroom only if they are invited to do so by the
impact and globalization due to current technology. As the homeroom teacher. School nurses in the school health cen-
dating relationship between adolescents progresses over ter are not allowed to contribute their expertise to this issue.
time, the opportunities for physical intimacy and interaction A consequence of this ruling is the reduction in access to
increase. Young males are more focused on engaging in sex counseling and support for teenagers when confronted with
than the female. However, due to the emotional aspects of personal situations of a sexual nature. This loss needs to be
the relationship and possible pressure tactics of the boy- rectified at the government and education board levels in
friend, a girl may acquiesce to sex. Sexual behavior among order to improve the level of sex education. School nurses
adolescents is not based on mature relationship skills and are the most well-educated resources on sexual education
concepts but is a stage in development with far-reaching on campus and the position of knowledge outsider offers
effects. Learning to exercise self-control at this developmen- some personal security to students (Croghan, Johnson, &
tal stage is an important stage in the maturation of the young Aveyard, 2004; Piercy & Hayter, 2008). Due to the
adult. The current Taiwanese study suggests that peer increase in sexual activity among Taiwanese teenagers

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Chang et al. 427

(Health Promotion Administration, Ministry of Health and Acknowledgment

Welfare, 2010), school nurses in Taiwan are in an excellent The authors thank the adolescents who willingly shared their per-
position to be involved in sex education and their knowl- spective with us and made this research possible.
edge could beneficially influence the educational depart-
ment’s policies. Teachers and pupils also agree that Declaration of Conflicting Interests
nurses can make a distinctive and positive contribution to
The author(s) declared no potential conflicts of interest with respect
sexual health education. Nurses and teachers must share to the research, authorship, and/or publication of this article.
roles in sexual education (Lightfoot, & Bines, 2000).

Limitations Funding
Although the findings were in accordance with other The author(s) disclosed receipt of the following financial support
for the research, authorship, and/or publication of this article: This
research, this was a relatively small, qualitative study. The
study was funded by Tzu Chi College of Technology (TCCT-
sample was drawn from only three high schools. Among the 1001A13), Taiwan.
47 adolescents, more than half were aboriginal students.
Additional research involving a much larger and more
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