Sex differences in the association of childhood sexual abuse severity with premarital sex among Chinese college students in Luzhou, China

In most countries, the shift towards later marriage in recent decades has led to an increase in premarital sex, making sexual health in relation to premarital sex an important public health issue [1]. Contemporary Chinese college students have open attitudes towards premarital sexual behaviour, and premarital sex is common among college students [2]. The premarital sex rate reported in China from 2011 to 2019 ranged from 13.36 to 30.4%, accompanied by an increasing trend year by year [3‐5]. Limited precollege sex education and the increasingly open sexual attitudes [6] of college students regarding one-night stands, sex without condoms, multiple sex partners, and other risky premarital sexual behaviours have resulted in a high incidence of unwanted pregnancies, abortion, HIV and other sexually transmitted infections, which are a potential source of concern for the sexual physiology and psychosexual health of college students [7‐9]. Chinese university students who are sexually active have a high incidence of premarital sex, and the average age of these students is only 20.14 ± 2.98 years [10]. The factors influencing premarital sex are numerous and complex, and they include peer sexual behaviour, media messages, family environmental factors, parental and personal attitudes towards premarital sexual behaviour, etc. [11‐13]., Among these factors, the influence of adverse childhood experiences, especially childhood sexual abuse (CSA) [14, 15], on premarital sexual behaviour has attracted the attention of researchers.

CSA, as a common adverse childhood experience, is a well-known risk factor for adolescent psychology and behavioural health problems. Under the influence of China’s traditional Confucian ideology and culture, adolescents who experience CSA are labelled as having destroyed chastity (for females) and integrity (for both males and females), leading to CSA being a taboo subject for adolescents who experience it and their parents [16]. However, in China, CSA is common and highly prevalent, with several studies in recent years reporting CSA rates ranging from 12% to 27% [17‐20]. As a result, the experience of CSA may increase the likelihood of risky sexual behaviours and adverse reproductive health outcomes in early adulthood [18], which may also lead to long-term adverse effects [21, 22]. Studies in the United States have shown that adolescents with adverse childhood experiences are at higher risk of early sexual debut [23]. Earlier findings from our research group also showed that middle school students who had experienced CSA were more likely to have open attitudes about premarital sex [24]. However, there are relatively few studies in China on whether CSA experiences directly affect individuals’ premarital sexual behaviour.

The effects of CSA experiences on health vary from person to person and include low self-esteem, anxiety, or panic disorder in mild cases; depression or nonsuicidal self-injury in moderate cases; and suicide or even death in severe cases [17, 25, 26]. This may be related to the individual and the exposure to different levels of CSA severity. In addition, a large study in China suggested a dose‒response relationship between the types of child abuse experienced and mental health [27]. It is evident that adverse childhood experiences are associated with mental health and are also likely to influence individual behaviour. We are interested in whether adolescents with experiences of different severities of CSA behave differently in terms of premarital sex. To fully explore the relationship between CSA severity and premarital sex among college students, this study referred to a definition of CSA similar to that in our earlier article, which defined CSA as sexual harassment, sexual molestation, and sexual assault [24].

Men engage in significantly more premarital sex than women [28]. Furthermore, the CSA rate among females is twice that among males [29], and the nature and extent of child maltreatment differs between the sexes [30], as do the resulting negative health outcomes [26]. If different levels of CSA severity affect premarital sex, are there sex differences in the effects? Only one study discovered that sex modifies the effects of CSA on health, implying that the effect of child maltreatment on the risk of depressive symptoms in college students is moderated by sex, with a greater effect in females than males [27]. However, it is unclear whether sex modifies the effect of CSA severity on premarital sex.

To our knowledge, there is a dearth of studies investigating the associations between the levels of CSA severity and premarital sex in college students, and no study in China has assessed the moderating effect of sex on these associations. Therefore, we conducted this cross-sectional study among college students to explore the effects of different levels of CSA severity on premarital sex behaviour, as well as the moderating role of sex on these effects. These findings will have implications for the prevention of CSA and the promotion of reproductive health in the college population.

We found a relationship between CSA experiences and early adult sexual behaviour and a cumulative effect among different severities of CSA experiences and premarital sex, with higher rates of premarital behaviour reported by students who had experienced more severe CSA. Additionally, there was a sex difference in this relationship, with a greater effect in males than females. Therefore, it is important to break gender stereotypes and consider the severity of CSA experiences, especially for protection against and prevention of adverse health consequences of early CSA in boys.

We found that 22.42% of college students had engaged in premarital sex and 9.39% had experienced CSA, with 4.04%, 2.90% and 2.46% experiencing mild, moderate and severe CSA, respectively. The rate of reported premarital sex in this study was higher than the rates in Taiwan [32], Wuhan [33] and India [34], and The rates of CSA in this study were somewhat lower than those reported in other studies [19, 35]. This may be due to differences in study populations, behavioural definitions, and measurement instruments or because CSA rates are indeed declining while the premarital sex rate is rising.

Additionally, this study found that after controlling for other confounding factors, the rate of reported premarital sex was 2.36 times higher among students who had experienced CSA than among those who had not. This is similar to the results of another Chinese study [30], in which adolescents who had experienced CSA were at higher risk of early sexual debut. In addition, we found a cumulative effect of CSA severity on premarital sex, with aOR values increasing from 1.81 to 2.18 to 3.25 as CSA severity increased from mild to severe, respectively. In other words, a cumulative effect was found, as the odds of premarital sex increased with the increasing severity of CSA. This finding is similar to a previous study that reported a dose‒response relationship between CSA and mental health problems [27]. One possible reason for this result is that the experience of CSA may affect an individual’s sex-related beliefs and subjective norms. The theory of planned behaviour (TPB) indicates that individual behaviour is influenced by subjective norms [36], and perpetrators are not punished accordingly, individuals who experience CSA may change their subjective norms, such as social morality regarding sexual behaviour, and be more likely to engage in unsafe premarital sex, such as one-night stands or commercial sex. Notably, this effect was more pronounced in individuals who had experienced severe CSA than in those who had experienced moderate and mild CSA. Similar relationships between CSA and murderous behaviour were reported in another study [37]. Official CSA prevention and control organizations are still lacking in China, and school- and family-based sex education is optional. Therefore, the results of this study suggest that among individuals who experience CSA, those who experience moderate to severe CSA should be identified and assessed by interventionists and administrators.

We investigated whether sex plays a moderating role in the relationship of CSA severity with premarital sex. There was a significant sex difference in the relationship between CSA and premarital sex, and this relationship held true after sex stratification. Compared to females who had experienced CSA, males who had experienced CSA reported a higher rate of premarital sex. Similarly, Tesfaye et al. also reported this sex-dependent phenomenon [38]. In addition, a previous study also considered the same trend [39]. Two possible reasons for these findings are as follows. First, cultural differences cause individuals in Eastern cultures to be relatively conservative, while traditional Chinese culture emphasizes female chastity and integrity [12]. In intimate relationships, female victims of CSA may be cautious about having premarital sex due to fear of revealing their past experiences. At the same time, as reported by Xiaoliang Chen et al. [27], the aforementioned reasons may lead to female respondents’ reluctance to disclose their CSA experiences, leading to an underestimation of the relationship between CSA and premarital sex in the female population. In addition, influenced by the division of labour, men hold the initiative and a dominant position in sexual activities [40, 41]. Coupled with the pursuit of ideal masculinity in men, the experience of CSA may have implications for the sexual rights and status corresponding to male roles in traditional Chinese social and cultural contexts [39, 42]. This means that the experience of CSA may expose men to more self-esteem conflicts, and they may try to prove their dominance and initiative by having sex in adult relationships. However, boys are perceived to be at lower risk of experiencing CSA than girls, resulting in the health risks of male CSA being underappreciated. Therefore, it is important to break the gender stereotype to communicate that sexual abuse is harmful to all children and adolescents, and it is especially important to increase protection from sexual abuse for boys.

This study also has several limitations. First, this was a cross-sectional study, so the ability to draw causal inferences and validate underlying mechanisms is limited. Second, recall bias is inevitable when study participants self-report their CSA experiences, but this bias should still be relatively small for those who experienced moderate to severe CSA. In addition, the results of this study represent only the population of college students in Luzhou City, and the extrapolation of the findings is limited by environmental factors such as economic development and education level. A larger sample is also needed to verify the results. Finally, questions regarding both CSA and premarital sex are sensitive, and there may have been instances when the respondents concealed the facts, causing the results to be underestimated. Despite these shortcomings, to our knowledge, the present study is one of the few studies examining the relationship between CSA and premarital sex among Chinese college students and considering the cumulative effects of CSA severity and sex differences.

This study found higher premarital sex rates among college students. There was a positive relationship between CSA experience and premarital sex and a cumulative effect between premarital sex and CSA severity; that is, the more severe the CSA experience was, the higher the rate of reported premarital sex among college students. There were sex differences in this relationship, which showed a more pronounced relationship among male students who experienced CSA. This study elucidates the effects of CSA on premarital sex in Chinese college students, especially among males, which can contribute to a better understanding of potential sex differences in the relationships among different severities of CSA and premarital sex and provides a scientific basis for the development of sex-specific and severity-specific CSA prevention and intervention approaches, as well as for the promotion of sexual and reproductive health among university students.