630808

research-article2016

JARXXX10.1177/0743558416630808Journal of Adolescent ResearchZhao et al.

Article

Communication
Between Asian American
Adolescents and
Health Care Providers
About Sexual Activity,
Sexually Transmitted
Infections, and Pregnancy
Prevention

Journal of Adolescent Research

122
The Author(s) 2016
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DOI: 10.1177/0743558416630808
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Jessie Zhao1,2, May Lau3, David Vermette4,

David Liang5, and Glenn Flores6

Abstract
Asian American adolescents have been reported to have the lowest amount
of communication with health care providers regarding sexual health
topics (sexual activity, contraception, sexually transmitted infections, and
pregnancy prevention). This study identified Asian American adolescents
attitudes/beliefs regarding how health care providers can be most helpful in
communicating about sexual health topics. Twenty participants revealed the
following information: (a) confidentiality concerns resulted in lying to health
care providers about sexual histories or refusing hormonal contraception,

1New

York University Langone Medical Center, New York City, USA

York University School of Medicine, New York City, USA
3UT Southwestern Medical Center and Childrens Medical Center, Dallas, USA
4UT Southwestern Medical School, Dallas, USA
5Texas Childrens Pediatrics, Houston, USA
6Medica Research Institute, Minneapolis, MN, USA
2New

Corresponding Author:
Jessie Zhao, Department of Pediatrics, New York University School of Medicine, 550 First
Avenue, NBV 8 South 4-11, New York, NY 10016, USA.
Email: Jessie.Zhao@nyumc.org

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Journal of Adolescent Research

(b) a general lack of knowledge regarding sexual health topics, and (c) a
hesitancy to discuss sexual histories with Asian American health care
providers. Asian American adolescents expressed a need for privacy from
parents regarding their sexual behaviors, and want health care providers to
initiate conversations and provide information about sexual health topics.
Keywords
Asian American, adolescents, sexuality, contraception, sexually transmitted
infections, pregnancy prevention
Health care providers play an important role in providing accurate information to adolescents about their sexual health issues, including prevention of
pregnancy and sexually transmitted infections (STIs). Adolescents report
finding it helpful to talk directly with a physician about sexual health topics,
such as STIs and pregnancy prevention (Rosenthal etal., 1999; Schuster,
Bell, Petersen, & Kanouse, 1996), with most parents supporting health care
provider counseling (Croft & Asmussen, 1993). Only about half of adolescents, however, routinely discuss their sexual health with health care providers (Jones, Biddlecom, Hebert, & Milne, 2011). Barriers to communication
between health care providers and adolescents regarding sexual health
include adolescents concerns regarding confidentiality and failure of health
care providers to raise the topic or respond to adolescents questions
(Rosenthal etal., 1999; Schuster etal., 1996). Previous studies found that
receiving sex education prior to first sexual intercourse was associated with
delaying initiation of sexual activity and greater use of contraception for sexually active adolescents (Landry, Singh, & Darroch, 2000; Muller, Gavin, &
Kulkarni, 2008; Tremblay & Ling, 2005). Many professional medical organizations recommend that health care providers obtain a sexual history and
provide counseling about sexual topics for all adolescents (American
Academy of Pediatrics, 2001; American Medical Association, 1999;
American Public Health Association, 2005). There has been limited research,
however, on how to best provide quality, effective discussions about sexual
health with Asian American adolescents in a culturally sensitive manner.
Asian Americans are the fastest growing minority group in the United
States, outpacing Latinos (U.S. Census, 2010). Despite this, limited research
has being conducted on Asian American adolescents. Most research on Asian
American adolescents focused on substance use, receipt of mental health services, exposure to youth violence, and obesity. Few studies have focused on
Asian American sexual health in the context of general adolescent health

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Zhao et al.

across all races/ethnicities. Prior works on Asian American adolescent sexual

health addressed sexual activity (Hahm, Lee, Rough, & Strathdee, 2012;
Lowry, Eaton, Brener, & Kann, 2011), safe and unsafe sexual practices
(Hahm etal., 2012; Lowry etal., 2011), and maternal influences on sexual
initiation (Kao, Loveland-Cherry, & Guthrie, 2010).
Although studies suggest that Asian Americans tend to have a normative
cultural value of more conservative attitudes toward sex, health care providers mistakenly may assume that Asian Americans are at low risk for risky
sexual behaviors; this model minority stereotype creates additional barriers
for Asian Americans when seeking sexual health services (Hahm, Lahiff, &
Barreto, 2006; Lee & Rotheram-Borus, 2009; Okazaki, 2002; Schuster, Bell,
Nakajima, & Kanouse, 1998). Research demonstrates that Asian American
adolescents age and young adults age of sexual debut and risk of acquiring
STIs are comparable with Whites (Hahm etal., 2006; Hou & Basen-Engquist,
1997; Kuo & St Lawrence, 2006). Compared with their peers, Asian American
adolescents and young adults are less likely to report using condoms during
their last sexual intercourse, less knowledgeable about HIV transmission and
prevention (Kuo & St Lawrence, 2006; Schuster etal., 1998), and have lower
rates of HIV screening (Centers for Disease Control and Prevention, 2013).
This may be due to Asian American adolescents and young adults having the
lowest rates of communication about STIs with health care providers, compared with those of other racial/ethnic groups (Adams, Husting, Zahnd, &
Ozer, 2009). It is especially important for health care providers to discuss
sexual health topics with Asian American adolescent patients, because many
receive little to no information from their parents about sexual health, contraceptives, or pregnancy prevention (Jones etal., 2011; J. L. Kim & Ward,
2007), as these discussions are generally regarded as taboo in Asian cultures (Jones etal., 2011; Okazaki, 2002).
Studies have shown that sexual risk-reduction efforts are more effective
when tailored to a specific racial/ethnic group and their particular culture
(Ellis & Grey, 2004). Prior research recommends that health care providers
discuss with Asian American adolescents healthy sexual practices, including
contraception, STIs, and pregnancy prevention, in a culturally sensitive manner that takes into account cultural, language, and religious preferences
(Grunbaum, Lowry, Kann, & Pateman, 2000; Hou & Basen-Engquist, 1997;
Lau, Markham, Lin, Flores, & Chacko, 2009). Given the role that health care
providers play in discussing sexual health with adolescents, and the low rate
of these discussions with Asian American adolescents (even though they are
engaging in high-risk behaviors like their peers), health care providers may
want to prioritize discussing sexual health with every Asian American adolescent. The study aim, therefore, was to identify the attitudes and beliefs of

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Journal of Adolescent Research

Asian American adolescents regarding how health care professionals can be

most helpful when communicating about sex, contraception, STIs, and pregnancy prevention.

Method
Study Design and Recruitment
A convenience sample of Asian American adolescents 14 to 18 years old was
recruited from different sites within the Asian American community in a
southwestern city to complete a background survey and one-on-one semistructured interview. The participants were primarily recruited from the suburb of a southwestern city with a median income of US$71,000. The primary
form of sexual education taught in schools emphasizes abstinence, and the
amount of teaching regarding sexual health, STIs, and pregnancy prevention
varies from classroom to classroom. The first author, a young Chinese
American female medical student (during the study period), recruited the
adolescents and conducted all surveys and individual interviews.
Adolescents were either approached by the first author or contacted the
first author after seeing a poster or hearing about the study through word-ofmouth. An attempt was made to recruit equal numbers of females and males,
and a spectrum of ages. Adolescents were recruited from several different
locations in the community, including bubble tea cafs, malls, and a Chineselanguage school. Adolescents were not recruited from a health care setting,
such as a hospital or clinic. A uniform set of recruitment documents in English
was made available to every interested adolescent, consisting of an informational flyer, a letter to the parent, and parental consent and adolescent assent
forms. All participants parents confirmed that they were able to read and
understand English.
Consent was obtained from participants who were 18 years old. For adolescents less than 18 years old, parental verbal and written consent, and adolescent assent were obtained. For parents who did not sign the consent form
in person, the consent form was read to the parent over the phone, and the
signed consent form was brought by the participant to the interview session.
Participants and their parents were notified that all data collected from the
study would remain confidential, with names and other personal identifiers
removed, and that only the study staff would have access to the information
contained in the background survey and one-on-one interview. A US$30 participant honorarium was provided to participants. The study was approved by
the Institutional Review Board of the University of Texas Southwestern
Medical Center.

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Zhao et al.

Study Protocol
The study took place in a 1-hour session in a private room in a public library.
Participants first completed a background survey in English lasting approximately 20 minutes, with two open-ended and 49 multiple-choice questions.
The background survey consisted of (a) sociodemographic questions about
age, gender, grade in school, zip code, family structure, number of years as a
U.S. resident, the primary language spoken at home, country of birth, and
country of parental ancestry; (b) sexual, contraceptive, and pregnancy history, and age of menarche (for females); and (c) the Asian Values Scale
(AVS), a brief 25-question survey that measures the participants adherence
to traditional Asian cultural values (B. S. K. Kim & Hong, 2004). Topics
addressed in the AVS include conformity to norms, family recognition
through achievement, emotional self-control, collectivism, humility, and
respect for elders. AVS scores range from 1 (least adherent) to 4 (most adherent). Written permission was obtained from the primary author of the AVS for
use in this study.
After the background survey was reviewed for completion and content by
the first author, the adolescent was interviewed for approximately 30 minutes.
The one-on-one semistructured interview explored adolescents attitudes and
beliefs about how health care providers can be most helpful in communicating
to Asian American adolescents regarding sex, contraception, STIs, and pregnancy prevention (Table 1). The seven questions in the interviewers guide
were developed from a review of the literature on sexual health topics pertinent to adolescents, the second authors previous experience working with
adolescents (particularly Asian Americans), and the first and second authors
discussions of potential barriers when communicating with Asian American
adolescents regarding sexual health. The initial questions were open-ended,
and participants were allowed to freely express themselves without interruptions. Probes were then used to clarify and expand on answers. Pertinent novel
topics that were brought up by adolescents in interviews conducted earlier
were subsequently included in later interviews. Each participant was only
interviewed once. All interviews were audiotaped and conducted by the first
author to ensure consistency.
The background survey, interview questions, and subsequent probes were
written at an eighth-grade reading level using colloquial terms. For example,
the term birth control was used instead of contraceptives; birth control
specifically was defined as referring to all types of contraceptives, with
examples (such as condoms, pills, and patches) provided. STIs were referred
to as sexually transmitted diseases (STDs). Health care providers were
referred to as doctors or nurses.

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Journal of Adolescent Research

Table 1. Interviewers Guide: Domains and Questions.

Domain
Sex
Contraception
Sexually transmitted
infections
Pregnancy prevention
Race/ethnicity

Communication

Question
How can doctors or nurses be most helpful when talking
about sex to you or other Asian American teens?
How can doctors or nurses be most helpful when talking
about birth control to you or Asian American teens?
How can doctors or nurses be most helpful when talking
about STDs to you and other Asian American teens?
How can doctors or nurses be most helpful when talking
about pregnancy prevention to you and other Asian
American teens?
When talking about healthy sexuality with a doctor or nurse:
how does his or her race/ethnicity affect how you act
toward or what you say to the doctor or nurse?
do doctors or nurses treat you differently because you are
Asian American?
A lot of teens do not talk to a doctor or nurse about
healthy sexuality. How do you think we can change this?

Note. STDs = sexually transmitted diseases.

Analyses
Audiotaped interviews were transcribed verbatim by either the first author or
staff unaware of the study objective. The first author verified the accuracy of all
transcripts. Three authors (J.Z., D.V., D.L.) independently coded and analyzed
the final transcripts and developed the initial taxonomy of themes regarding
communication between health care providers and Asian American adolescent
about sexual health. All transcripts were reviewed to identify themes. The second author reviewed a 20% sample of the transcripts to ensure consistency.
Transcripts were analyzed using thematic content analysis, in which key themes
are identified and transformed into codes, words, or phrases that serve as labels
for sections of data. The codes from one transcript were compared with other
transcripts to identify similarities and differences. This method allows for the
organization and description of data in rich detail (Guest & MacQueen, 2012).
A final taxonomy of themes was developed by the first two authors.

Results
Sociodemographic Characteristics
Forty-eight adolescents were initially approached, of whom 20 completed the
study (Figure 1). The most common reason for nonparticipation was a dislike

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Zhao et al.

Figure 1. Flow diagram of sampling frame and number of Asian American

adolescents sexually active and using contraception.

of the study topic, followed by lack of time and lack of parental consent. The
mean participant age was 16.7 years old; half were male (Table 2). Of the 20
participants, seven were Vietnamese, five were Chinese, two were Korean,
two were Laotian, two were Thai, and two were Filipino. Eighty-five percent
were born in the United States. The primary language spoken at home was
English for 55% of the participants; 80% of participants lived with both parents; and all but one participant had seen their regular health care provider
within the past 2 years. The mean AVS score was 2.5, with a standard deviation of 0.172 and a range of 0.6. The mean age of menarche for females was
12.1 years old.

Sexual Behaviors of Participants

Almost half of participants were sexually active, defined as having had oral,
vaginal, or anal sex (Table 3). One tenth of the participants had oral sex; none
of the participants had anal sex. Only about 20% of sexually active participants always used condoms with vaginal or oral sex. Although most participants had seen their primary health care provider within the past 2 years,
almost two thirds had never discussed dating, STIs, sex, contraception, or
abstinence with their health care provider; none of the participants had

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Journal of Adolescent Research

Table 2. Sociodemographic Characteristics of Study Adolescents (n = 20).

Characteristic

M or proportion

Age (years)
Grade
Female
Ethnicity
Vietnamese
Chinese
Filipino
Thai
Korean
Laotian
Primary language spoken at home is English
Born in the United States
Asian Values Scale score
Family structure
Both parents live at home
Single parent
Seen regular health care provider in past 2
years

16.7
11.7
50%
35%
25%
10%
10%
10%
10%
55%
85%
2.50
80%
20%
95%

aAsian Values Scale measures adherence to traditional Asian cultural values and ranges from 1
(least adherent) to 4 (most adherent).

discussed pregnancy prevention with their health care provider. Teachers and
friends were the most common sources of sexual health information. Parents,
health care providers, and magazines were the least common sources. No
participant had ever been pregnant or impregnated a female partner.
Several key themes were identified (Table 4).
Communications regarding sexual health. Asian American adolescents desired
to have health care providers initiate conversations about sexual health, as
they are often too embarrassed or afraid to bring up the topic. One 18-yearold female said,
I want to confide that with the doctor, if I cant tell my parents, you know. Say,
about a year ago I started being sexually active, I would have liked to talk to the
doctor, to make sure I was OK, cuz you know, I didnt have another adult
figure to talk to.

Another 17-year-old female agreed that it is very difficult to bring up sexual

health topics, but would appreciate an opportunity to discuss sex: Some

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Zhao et al.
Table 3. Sexual Behavior Characteristics of Study Adolescents (n = 20).
Characteristic

M or proportion

Sexually active
Sexually active and engaged in oral sex only
Sexually active and used condoms
Always
Sometimes
Never
Discussed sexual health topics with regular health care providera
None
Abstinence
Dating
Sexually transmitted infections
Sex
Contraception
Pregnancy
Sources of sexual health informationa
Teachers
Friends
Internet
TV
Parents
Health care providers
Magazines
M age of menarche for females (years)
aDoes

45%
10%
22%
55%
22%
65%
15%
15%
15%
5%
5%
0%
85%
85%
65%
65%
40%
25%
20%
12.1

not sum to 100% because more than one response could be chosen.

teens maybe are scared to ask about sex themselves. So if the doctor presents
an opportunity for them, then I think they would more than likely to take it.
Adolescents recommended that health care providers initiate these conversations during regular checkups and with both sexually active and abstinent
adolescents.
Confidentiality. Asian American adolescents were unaware of provider-patient
confidentiality regarding sexual health discussions. Adolescents stated that
they would be more open and honest with their health care providers if clinicians informed adolescents about their right to confidential care. One 16-yearold male stated, I definitely think confidentiality is the first thing they should
say. It was of utmost importance to Asian American adolescents that conversations regarding sexual health occur without parents in the room to prevent
disclosure of their dating and sexual history to their parents. Asian American

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Table 4. Taxonomy of Themes From Interviews Regarding Communication

Between Asian American Adolescents and Health Care Providers.
How health care providers can be most
helpful in communicating about sexual
health
Initiate conversation with both
sexually and nonsexually active
adolescents
Initiate conversation during regular
checkup or physical exam
Build long-standing relationship to
develop trust and honesty
Emphasize health care provider-patient
confidentiality
Discuss sexual health without parents
in room
Discussing confidentiality leads to
more open and honest conversations
How health care providers can be
most helpful in communicating about
contraception
Discuss importance of contraception
Educate about different types and
their efficacies, inconveniences, side
effects, and costs
Recommend specific type to patient
Discuss noncontraceptive medical
uses of hormonal contraception
Barriers to contraceptive use
Fear parents will find out about
sexual activity
Lack of access
Lack of financial resources
Lack of knowledge about
contraceptives
Lack of knowledge about STIs
How health care providers can be most
helpful in communicating about STIs
Educate about different types,
symptoms, and transmission
Emphasize condoms are the only
contraceptives protective of STIs
Show pictures of symptoms
Offer to prescribe contraception
Offer STI testing
Explain Human Papillomavirus (HPV)
vaccine

Barriers to knowledge about sex, STIs, and

contraception
Never discussed sexual health with
parents
Not taught in school
How health care providers can be
most helpful in communicating about
pregnancy prevention
Emphasize abstinence and discuss
negative effects of pregnancy in terms
of future occupational or career goals
Emphasize abstinence with both
sexually and nonsexually active
adolescents
Encourage contraceptive use
Asian American adolescents more
hesitant to discuss sexual activity with
Asian American health care provider
Asian health care provider more likely
breach confidentiality
Asian health care provider more
judgmental
Asian adolescents more likely lie to
Asian American health care provider
about sexual history
Prefer American-born Asian health
care provider over foreign-born Asian
health care provider
Health care providers less likely to discuss
sexual health with Asian American
adolescents
Stereotype Asian American adolescents
as not sexually active
Barriers to open dialogue between
health care provider and Asian
American adolescents
Fear of breach of confidentiality by
health care provider
Fear of parental disapproval and
punishment
Health care provider of Asian descent
Topic of sexual health never initiated
Health care providers stereotype Asian
American adolescents as not sexually
active

Note. STIs = sexually transmitted infections.

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Zhao et al.

adolescents report frequently lying to health care providers to keep their sexual history concealed from their parents. One 18-year-old female exclaimed,
If my mom was even outside this door right now, I would not be saying
anything about my sexual activities. I would just be lying.
Communications regarding contraception.Asian American adolescents emphasized the importance of health care providers discussing different contraceptive
methods and their advantages and disadvantages. Participants related that it
also would be helpful for health care providers to recommend a specific type of
contraceptive.
In addition, female Asian American adolescents stressed the importance of
health care providers discussing noncontraceptive uses of hormonal contraception with adolescents and their parents. Asian American adolescents noted
that their parents knowledge regarding contraception is very limited; parents
often do not understand that hormonal contraception can be used for noncontraceptive reasons, such as dysmenorrhea or menorrhagia. One 18-year-old
female explained,
My periods are really irregular, so I actually do need birth control pills for more
things than just for sex, but my Mom wont believe that. Birth control to my
parents, especially to my Mom, is like, OK, well, now youre going to start
having sex. So its a big no, and Im like, thats not the whole reason why you
use it. Theres multiple reasons, but she wont believe that.

Barriers to contraceptive use. A main barrier to contraceptive use identified by

Asian American adolescents is parental opposition. Asian American adolescents fear that if the topic of contraception is brought up, parents will suspect
that they are sexually active and punish them. One 18-year-old female
explained, Im sure it wouldnt be hard to keep the pills in my purse, but if
my parents were to see that, Id have a lot of explaining to do.
Asian American adolescents identified many other access barriers to
obtaining hormonal contraception, including transportation issues to obtain a
prescription from a physician or the medication from the pharmacy, and limited financial resources. An 18-year-old female noted, I didnt have a car or
money to get started on birth control. More female participants than male
participants discussed barriers to obtaining hormonal contraception, whereas
male participants primarily discussed barriers to obtaining condoms.
Knowledge about sexual health. Asian American adolescents reported a general
lack of knowledge regarding STIs, compared with their non-Asian peers. One

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Journal of Adolescent Research

17-year-old male said, When I was 15, I didnt know STD was a sexually
transmitted disease. I thought it was just some kind of disease! Adolescents
expressed wanting to learn more about the different STI types, including their
acquisition and symptoms. One 16-year-old female stated, Doctors should
just give them more information about STDs. I think more information is
always better. For Asian people, all we know is its bad, and other than that, we
dont know anything else. In addition, many adolescents were unaware that
condoms are the only contraceptives that reduce the risk of STIs. A main contributing factor to Asian American adolescents general lack of knowledge
regarding STIs and contraception was a lack of discussion with parents about
sexual health. Adolescent conversations with parents consist of warnings to
delay dating and sexual intercourse for fear of pregnancy, disease, or negatively affecting grades. One 16-year-old female stated,
I asked my Mom, What is sex? and she said, Me and your Dad, we just fall
in love and after that we had you. So at that time, I seriously dont even know
what sex is until about like 8th grade, 7th grade, when they show you a tape, I
realize theres such thing called sex.

Another 17-year-old female related, When I talked to my Asian friends about

sex, they would be like, Oh really? I didnt know either. And Im like, wow,
that proves a lot. None of our parents like talked to us about anything.
Pregnancy prevention.Asian American adolescents noted that discussions
about abstinence would be more effective when the negative effects of pregnancy are framed in terms of future occupational or career goals. A 17-yearold female describes how she thinks health care providers should talk about
abstinence: Doctors can tell her abstinence is a good thing; and tell about, if
she was sexually active, all the STDs she can get, and how she can get teen
pregnancy, and how it would affect her career and stuff. Asian American
adolescents were particularly concerned about the effects of pregnancy and
raising a child on graduating high school and on college opportunities. A
17-year-old male said, Asian American students, theyre academically competitive, and so the fact that they may not be able to complete high school or
go to college probably affects them negatively. Participants desired health
care providers to discuss abstinence with all adolescents, regardless of sexual
activity history.
Asian health care providers.Asian American adolescents stated that they are
more hesitant to discuss their sexual activities and sexual history with Asian
health care providers, who were viewed as more likely to breach confidentiality

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Zhao et al.

and be more judgmental. Adolescents feared that an Asian health care provider
would feel a duty to tell adolescents parents about their sexual behaviors.
One 16-year-old female describes her fears:
Asian people can relate to other Asian people; maybe the doctor might relate to
your parents more, and he might break the confidentiality that he agreed to.
And I feel like, maybe based on his own views and opinions, he might feel like
your situation is different and let your parents know.

In addition, Asian health care providers were viewed as more judgmental

about sexual behaviors. One 18-year-old female remarked,
I feel like, when it comes down to sexual activities, you would probably be less
willing to talk about it with an Asian doctor. Because, from like, when you
grew up and everything, you already have this mind-set that the Asian people
dont approve, and whenever you tell them about it, then you would probably
feel like they might not approve, and you probably wouldnt tell them about
what youve been doing or anything like that.

As a result, Asian American adolescents state that they are more likely to
lie to an Asian health care provider about their dating and sexual history. One
18-year-old female dramatically said, I have to lie to an Asian doctor. I cant
be honest around my parents. If I say, Yes Ive had sex, then all the yelling
and arguing starts, all the stress starts. I dont wanna deal with that.
Participants also stated that the Asian health care provider was often chosen
for them by their parents due to prior social or professional relationships,
adding an additional barrier to honest and open communication.
Asian American stereotypes. Participants reported that health care providers
stereotype Asian American adolescents as not sexually active, and thus are
less likely to discuss sexual health with them. One 17-year-old female noted,
The Asian stereotype might be really hardworking, you know, does good in
school, and whenever you bring up something like, Oh, I had sex, then it
would be something more out of your stereotypical norm, and doctors would
probably not view it as highly as maybe if a White person did it or something.

Other participants supported this theme; one 17-year-old male said, Im sure
the stereotype is that if theyre Asian, theyre not gonna do anything, but I
mean, the fact of the matter is there are Asians doing something. Asian
American adolescents emphasized that this stereotype impedes discussions
of sexual health topics with health care providers.

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Gender differences.Female participants were generally more expressive

when discussing hormonal contraceptives and pregnancy prevention, especially the barriers that they face when trying to obtain hormonal contraception. Although one male participant did discuss in detail hormonal
contraception use by his sexual partner, most male participants, instead,
focused on condoms as their main pregnancy-prevention tool. One 18-yearold male stated that the only contraception he was familiar with as far as I
know, is a condom. Both female and male participants placed equal importance on confidentiality and STI prevention. In addition, more females than
males expressed frustration regarding boundaries placed by their parents on
their dating and sexual behaviors. Multiple male participants reported that
their parents somewhat knew and accepted their dating history. One
17-year-old male stated, I told my mom one time that I had sex, and I was
just joking around. I never told her I was joking, I just made it in a joking
way, but she just went along with it. He continued to say that his parents
were relaxed about sex, and that they trust me, and I know that they trust
me. In contrast, females described needing to keep their dating history
absolutely private. Females, in general, also emphasized more than males
their lack of sexual knowledge, and multiple female participants asked the
first author questions regarding physiology and disease throughout the
interview.
Differences based on history of sexual activity. Less than half of the participants have participated in oral or vaginal sex. Sexually experienced participants were more communicative during the interviews and had more
in-depth responses to interview questions. As expected, sexually experienced participants were generally informed about sexual health topics,
including STIs and pregnancy prevention. Many expressed that the study
topic was important to them and something they thought about often. One
sexually active 18-year-old female reported that, immediately upon seeing
the flyer for this study, she knew she wanted to help out, as this was an
area that was very interesting to her. Participants related anecdotes about
their positive and negative experiences with health care workers regarding
sexual health, and discussed, in detail, ways in which this communication
could be improved, particularly in regard to Asian health care providers.
The same 18-year-old female went on to discuss how her own health care
provider did not initiate the topic of sexual health with her because he
assumed she was a good kid, even though she was already sexually active
and wanted counseling on pregnancy prevention. Sexually active participants supported promoting abstinence first, but emphasized that it should
be discussed with contraception and STIs.

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Discussion
This is the first qualitative study, to our knowledge, specifically to examine
Asian American adolescents beliefs regarding discussions of sexual health
between health care providers and Asian American adolescents, and to identify barriers to these discussions. Certain barriers identified in this study are
similar to those identified in studies that examined sexual health discussions
in other racial/ethnic groups (Schuster etal., 1998); however, several specific
preferences regarding Asian American adolescents also were identified.
Asian American adolescents identified health care provider confidentiality as critical for conversations regarding sexual health. Confidentiality was
cited by Asian American adolescents as essential for them to be comfortable
and honest in discussions regarding their sexual history, STIs, contraception,
and pregnancy prevention. Previous studies have shown that adolescents
know little about the protections of confidentiality regarding sexuality issues
(Ford, Thomsen, & Compton, 2001), and that they are more willing to communicate with physicians who assure confidentiality (Ford, Millstein,
Halpern-Felsher, & Irwin, 1997). This is especially relevant to Asian
American adolescents, as findings from this study suggest that Asian
American adolescents pertinently prioritize confidentiality regarding their
dating and sexual history. Asian culture, on average, tends to place high value
on sexual restraint, modesty, and sex only within marriage (Okazaki, 2002).
To comply with cultural norms, Asian American adolescents reported often
engaging in secret sexual activity against parental commands, and retain a
deep fear of parental knowledge of their sexual history. In a previous study,
many Asian American adolescents engaged in secret dating without their parents knowledge and proceeded directly to serious dating relationships, a pattern that has been associated with an earlier onset of sexual activity (Cooksey,
Mott, & Neubauer, 2002; Lau etal., 2009).
Due to concerns about confidentiality, Asian American adolescents
reported lying to health care providers, especially to Asian health care providers, about their sexual activities and refusing hormonal contraception.
This study was conducted in an urban center with a large, diverse network of
health care providers (both Asian and non-Asian), but participants health
care providers were usually chosen by their parents, regardless of the adolescents preferences. Many participants stated that their parents often selected
providers who had a prior relationship with the household, whether professional or social, which may have created a further barrier to open an honest
communication by the adolescent. A recent study has shown that conversations between adolescents and physicians where the physician explicitly discussed confidentiality were associated with higher likelihood of addressing

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Journal of Adolescent Research

sexual health topics (Alexander etal., 2013). In another study, one quarter of
adolescents would forgo health care if they had concerns about confidentiality (Cheng, Savageau, Sattler, & DeWitt, 1993), a number that might be
higher in Asian American adolescents, as indicated by our study findings.
Adolescents with confidentiality concerns have been shown to be more likely
to have increased depressive symptoms, suicidal ideation, and past suicide
attempts (Lehrer, Pantell, Tebb, & Shafer, 2007). The study findings, along
with recent research, suggest that it may prove useful for health care providers, particularly those of Asian race/ethnicity, and those with a prior relationship with the other family members, to discuss confidentiality at the start of
each visit with Asian American adolescents, and conduct sexual health conversations alone with the adolescent.
A lack of knowledge regarding sex, STIs, and contraception, when compared with their peers, was reported by Asian American adolescents. In a
recent study examining sexual health discussions between more than 200
adolescents and their physicians, no adolescent initiated conversations
regarding sexual health (Alexander etal., 2013). This study also reported that
Asian physicians were significantly less likely to have sexual health discussions with their adolescent patients, compared with White physicians, suggesting that the cultural stigma regarding sexual health not only affects
familial relations but also constrains health care providers. Given the lack of
knowledge reported by Asian American adolescents in this study, health care
providers may want to explicitly initiate educational discussions with Asian
American adolescents regarding sexual health topics.
This studys principal aim was to analyze communication between Asian
American adolescents and their health care providers, but the topic of adolescent-parental communication repeatedly arose as a major contributing factor
to adolescents overall sexual health. Participants cited parents influences on
their sexual behaviors and how relationships with their parents affected attitudes and knowledge regarding sexual health. Adolescents regard parents as
a major source of information about sex (Whitaker & Miller, 2000). Asian
mothers, however, are significantly less likely than mothers of other racial/
ethnic groups to discuss sexual health topics with their daughters (Meneses,
Orrell-Valente, Guendelman, Oman, & Irwin, 2006). This is possibly due to
cultural taboos about discussing sex, with parents not initiating discussions
regarding sexual health topics, combined with language barriers between parent and adolescent, and expectations for hierarchical familial relationships
that deter open and explicit communication across generations (J. L. Kim &
Ward, 2007). One study demonstrated that higher levels of mother-daughter
communication about sexual risks were associated with fewer episodes of
sexual intercourse and unprotected sex in African American and Latino

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Zhao et al.

adolescents (Hutchinson, Jemmott, Jemmott, Braverman, & Fong, 2003).

Another study identified an association between greater adolescent acculturation and less parent-adolescent communication about sex in Filipino American
families (Chung etal., 2007). Previous studies have shown that parental monitoring, role modeling, and perceived closeness between parent and child
are associated with fewer teenage pregnancies and less sexual activity
(Koniak-Griffin, Lesser, Uman, & Nyamathi, 2003). A recent study examining Asian American adolescents perceived parental expectations regarding
their sexual behaviors showed that consistent parental attitudes and modeling
behaviors were key to adolescents decision making about what sexual
behaviors were appropriate, and that adolescents were more likely to fulfill
their parents expectations for their sexual behaviors if their relationship was
more trusting, supportive, and open (Kao & Martyn, 2014). Health care providers can play a significant role in fostering open communication between
the parent and adolescent regarding sexual expectations. Consistent with our
study findings, previous studies reported that Asian American adolescents
want health care providers to provide guidance regarding improving communications with their parents about sexual health and resolving family conflicts regarding the adolescents dating and sexual habits (Vo, Pate, Zhao, Siu,
& Ginsburg, 2007).
Asian American adolescents view discussions of abstinence positively,
especially regarding their future educational or occupational goals. Medical
and public health organizations recommend discussions of abstinence within
a comprehensive sexual education program (American Academy of
Pediatrics, 2001; American Medical Association, 1999; American Public
Health Association, 2005). The study findings show that Asian American
adolescents desire health care providers to encourage abstinence for both
sexually active and abstinent adolescents, and discuss the effects of pregnancy and STIs on future college choices and career aspirations.
Certain study limitations should be noted. Although 48 adolescents initially were approached to participate in this study, only 20 completed the
study. This convenience sample may not be representative of the full range of
views held by all Asian American adolescents. The study was conducted in a
southwestern city where abstinence-only education is emphasized. The study
topic and recruitment materials (informational flyer) might possibly have
deterred some adolescents from participating; as this study required both
written and verbal consent from parents, some adolescents might have feared
that their desire to participate in the study would arouse parental suspicion
about their sexual history. Some nonsexually active adolescents might not
have participated in the study due to lack of interest in or embarrassment
about the study topic, and might have perceived that one of the study

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Journal of Adolescent Research

inclusion criteria was a history of sexual activity. Some sexually experienced

adolescents might not want to reveal their sexual history and behaviors to a
stranger, despite assurance of confidentiality. As stated above, male participants may not have been as open and expressive with a female interviewer. In
addition, given our findings that Asian American adolescents may view Asian
providers as more judgmental regarding sexual activity, the participants
might have been more reluctant to reveal their sexual attitudes and activities
to an Asian interviewer versus a non-Asian interviewer. The association
between AVS scores and themes regarding communication between Asian
American adolescents and health care providers was not examined, due to
insufficient sample sizes. Adolescents whose parents had limited English
proficiency were not included in this study, as we were unable to obtain consent in languages other than English, due to financial limitations.
There were several study strengths. This is the first qualitative study to
identify barriers to sexual health communications between health care providers and Asian American adolescents. A private one-on-one interview format was used, which facilitated open and honest responses. Participants were
recruited from the community, rather than from a health care setting. In addition, the authors believe that the interview data are trustworthy, in accordance
with Gubas criteria of credibility, transferability, dependability, and confirmability, to ensure trustworthiness in qualitative research (Shenton, 2004). The
data are credible, given that the first and second authors are both of Asian
descent and understand the Asian American adolescent culture, and the first
author was able to build trust with the participants by establishing that the
interviews would be confidential. The second author also has prior experience working with adolescents, especially Asian American adolescents. The
information revealed by the participants is viewed as reliable and honest, as
many participants expressed feeling comfortable discussing personal information with the first author. The data are dependable, with three authors, in
addition to the first author, auditing the data; the data also are transferable,
with descriptions of the organizations taking part in the study, recruitment of
participants, data collection methods, and analysis methods. For establishment of confirmability, the authors provide in-depth methodological descriptions (with the interviewers guide provided in Table 1) and documentation of
study limitations.
In conclusion, the study findings reveal that when communicating about
sexual health with Asian American adolescents, it may be most beneficial for
health care providers to discuss confidentiality before initiating conversations about sexual health, abstinence, STIs, and pregnancy prevention. Asian
American adolescents are less likely to be open and honest with Asian health
care providers regarding their sexual activity, but would be willing to be more

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Zhao et al.

open after discussions of confidentiality. Asian American adolescents also

report desiring more communication and education regarding sexual health
topics with health care providers. These findings suggest that, to prevent STIs
and pregnancy among Asian American adolescents, it might prove useful to
emphasize abstinence, encourage contraceptive use, and discuss the negative
consequences of STIs and pregnancy for future career goals.
Authors Note
This study was presented in part as platform presentations at the annual meetings of
the Pediatric Academic Societies on April 28, 2012, in Boston, MA, and the American
Federation for Medical Research Southern Regional Meeting on February 10, 2012,
in New Orleans, LA; and as a poster presentation at the annual meeting of the Society
for Adolescent Health and Medicine on April 17, 2012, in New Orleans, LA. The
abstract of this work was awarded the 2012 Academic Pediatric Association Research
Award for Best Abstracts by students.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research,
authorship, and/or publication of this article.

Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.

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Author Biographies
Jessie Zhao, MD, is a pediatric resident at New York University Langone Medical
Center in New York, NY. She attended the University of Texas Southwestern Medical
School.
May Lau, MD, MPH, is an assistant professor in the Department of Pediatrics at
University of Texas Southwestern Medical Center and a board-certified adolescent
medicine specialist at Childrens Medical Center, both in Dallas, TX. Her research
interests include racial/ethnic and reproductive health issues.
David Vermette, BS, MBA, is a medical student at the University of Texas
Southwestern Medical School.
David Liang, MD, is a pediatrician at Texas Childrens Pediatrics in Houston, TX. He
attended University of Texas Southwestern Medical School and completed his residency at Texas Childrens Hospital and Baylor College of Medicine in Houston, TX.
Glenn Flores, MD, is the Distinguished Chair of Health Policy Research at Medica
Research Institute in Minneapolis, MN. He is also director of the Academic Pediatric
Association Research in Academic Pediatrics Initiative on Diversity (RAPID), funded
by the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) .
His research interests include racial/ethnic disparities in childrens health and health
care, community-based interventions for improving the health and health care of
underserved children, insuring uninsured children, testing innovative interventions
for chronic disease management, and linguistic and cultural issues in health care.

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