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

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, (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 et al., 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 et al., 1999; Schuster et al., 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 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 et al., 2012; Lowry et al., 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 et al., 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 et al., 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 et al., 2011; J. L. Kim & Ward, 2007), as these discussions are generally regarded as “taboo” in Asian cultures (Jones et al., 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 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-of-mouth. 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 cafés, malls, and a Chinese-language 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.

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 participant’s 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 interviewer’s guide were developed from a review of the literature on sexual health topics pertinent to adolescents, the second author’s 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.

Table 1.

Interviewer’s Guide: Domains and Questions.

Domain	Question
Sex	How can doctors or nurses be most helpful when talking about sex to you or other Asian American teens?
Contraception	How can doctors or nurses be most helpful when talking about birth control to you or Asian American teens?
Sexually transmitted infections	How can doctors or nurses be most helpful when talking about STDs to you and other Asian American teens?
Pregnancy prevention	How can doctors or nurses be most helpful when talking about pregnancy prevention to you and other Asian American teens?
Race/ethnicity	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?
Communication	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.

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.”

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 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.

Figure 1.

Flow diagram of sampling frame and number of Asian American adolescents sexually active and using contraception.

Table 2.

Sociodemographic Characteristics of Study Adolescents (n = 20).

Characteristic	M or proportion
Age (years)	16.7
Grade	11.7
Female	50%
Ethnicity
Vietnamese	35%
Chinese	25%
Filipino	10%
Thai	10%
Korean	10%
Laotian	10%
Primary language spoken at home is English	55%
Born in the United States	85%
Asian Values Scale score	2.50
Family structure
Both parents live at home	80%
Single parent	20%
Seen regular health care provider in past 2 years	95%

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

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 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.

Table 3.

Sexual Behavior Characteristics of Study Adolescents (n = 20).

Characteristic	M or proportion
Sexually active	45%
Sexually active and engaged in oral sex only	10%
Sexually active and used condoms
Always	22%
Sometimes	55%
Never	22%
Discussed sexual health topics with regular health care provider^a
None	65%
Abstinence	15%
Dating	15%
Sexually transmitted infections	15%
Sex	5%
Contraception	5%
Pregnancy	0%
Sources of sexual health information^a
Teachers	85%
Friends	85%
Internet	65%
TV	65%
Parents	40%
Health care providers	25%
Magazines	20%
M age of menarche for females (years)	12.1

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

Several key themes were identified (Table 4).

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 honestyEmphasize 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 contraceptionBarriers 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 STIsHow 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 providerHealth 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.

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-year-old female said,

I want to confide that with the doctor, if I can’t 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 didn’t 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 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-year-old 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 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 won’t believe that. Birth control to my parents, especially to my Mom, is like, OK, well, now you’re going to start having sex. So it’s a big no, and I’m like, that’s not the whole reason why you use it. There’s multiple reasons, but she won’t 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, “I’m sure it wouldn’t be hard to keep the pills in my purse, but if my parents were to see that, I’d 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 didn’t 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 17-year-old male said, “When I was 15, I didn’t 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 it’s bad, and other than that, we don’t 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 don’t even know what sex is until about like 8th grade, 7th grade, when they show you a tape, I realize there’s 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 didn’t know either.’ And I’m 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-year-old 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, they’re 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 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 don’t approve, and whenever you tell them about it, then you would probably feel like they might not approve, and you probably wouldn’t tell them about what you’ve 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 can’t be honest around my parents. If I say, ‘Yes I’ve had sex,’ then all the yelling and arguing starts, all the stress starts. I don’t 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, “I’m sure the stereotype is that if they’re Asian, they’re 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.

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-year-old 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.

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 et al., 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 parent’s 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 et al., 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 sexual health topics (Alexander et al., 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 et al., 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 study’s 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 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 et al., 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 parent’s 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 adolescent’s 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 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 Guba’s 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 interviewer’s 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 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.

Footnotes

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.

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 Children’s 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 Children’s Pediatrics in Houston, TX. He attended University of Texas Southwestern Medical School and completed his residency at Texas Children’s 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 children’s 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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