Based on the definition of World Health Organization, sexual health is not merely the absence of disease or sexual problems. Still, it includes physical, mental, emotional, and social well-being concerning sexuality(1). Sexual health, as an essential part of public health, can affect health and quality of life(2). Due to the rising age of marriage, most young people initiate a premarital sexual relationship. In the U.S., the median interval between age of marriage and the first sexual relationship is reported as 8.7 and 11.7 years respectively (3). Sexual activity among never-married women in the United States has increased, and sexual abstinence decreased rapidly among women born in the late 1940s(4).
The prevalence of sexually transmitted infections (STIs) and the consequences of unwanted pregnancy in teenagers are the serious public health concerns and highlighted the potential risks of adolescent sexual activity worldwide(5). The majority of Americans initiate sexual activity before marriage in college, if not earlier (6) which predisposes them to sexually transmitted diseases, unwanted pregnancies, and unsafe abortions (5).
Various approaches have been used to delay sexual activity and prevent high-risk sexual behaviors in young people. As a healthy choice for adolescents, abstinence can prevent HIV, other sexually transmitted infections, and unwanted pregnancies. Abstinence-only until marriage (AOUM) as a unique approach for adolescent sexual health was established in 1981(3, 7). However, there is a lack of consensus on the effectiveness of abstinence programs in reducing the risky sexual behaviors (8). Comprehensive sex education and Sexual Risk Avoidance Education (SRAE) are the better strategies to delay the initiation of sexual relationships and change sexual risk behaviors (3, 9).
The decision to delay the sexual relationship is formed by individual, family, and socio-cultural factors. Sexual avoidance and its role in preventing high-risk behaviors vary in different cultures, communities, and geographies (8).
Despite the high prevalence of risky behaviors in the university setting, exposure and vulnerability to risky sexual behavior due to many biological and social determinants(2), freedom of living away from home , and increased exposure to mixed-gender environments (10, 11), few studies have focused on sexual patterns and abstinence in this population (12). This study was performed with aim to determine the abstinence rate and establish the associated factors among American university students.
Materials and Methods
This cross-sectional survey was performed on the university students from different countries attending Central Michigan University (CMU) in the United States of America in 2018-2019. The protocol of the study was approved by the Ethics committee of the Institutional Review Board) IRB) at CMU (IRB: 1031916–4).
We extracted a sampling frame from the Registrar’s office. A random sampling technique was used to send the email invitations to students in three phases and they were invited to participate in the study. If they agreed to participate in the study, an electronic questionnaire was sent to them. The inclusion criteria were registered students willing to participate in the study, and the exclusion criteria were reluctance to participate. The School of Health Sciences was not included in the sampling. Sample size (n=900) was calculated using the prevalence of 19%, expectant increase of 25%, 1.96 Z value, 5% of precision, power of 80% and 20% non-respondent rate(13, 14). A self-administered structured questionnaire was extracted from World Health Organization (WHO) questionnaire and was used for data collection (15). The World Health Organization illustrative questionnaire has been used many times in other countries and validated previously in several surveys (16-18). Missing data for each variable was in the range of 10% to 22%. The questionnaires were sent by Qualtrics online software.
STD/HIV knowledge score was estimated based on the information about the risk factors associated with having sex and the knowledge of how to practice safely using ten questions. A higher score on this scale indicates the higher level of knowledge. Due to its non-normal distribution as a continuous variable, knowledge was made dichotomous. Knowledge was divided into low and high, and the data was split around the median number of correct answers. Belief about the protection role of condoms and practice was measured with two and six true-false questions, respectively. Attitudes were assessed by the answer to the five questions with a choice of one of 3 answers (Agree=1, do not know/not sure=2, disagree=3). A higher score on this scale indicates a higher level of knowledge of condom use. A total score of sexual behavior (Sexuality, gender, and norms) was estimated by 23 questions with a choice of one of 3 answers (Agree=1, do not know/not sure=2, disagree=3). SPSS software (version 26.0) was used for statistical analysis. Descriptive and bivariate analyses were performed. The association between the independent variables and sexual abstinence was evaluated by logistic regression.
Among those who were approached to participate in the study, 808 students accepted to participate in the study and completed the survey (participation rate was 32.3 %.). However, some of the questions related to sexual relationships were left empty. Majority of respondents were females (n =636, 68.8%). The mean age of the students was 23.87 ±7.56 years. The majority were undergraduate (68.2%) and single (95.4%) (Table 1).
More than 460 (85.1%) of the university students had sexual intercourse in their life, while 81 (14.9%) didn't have. Of those who did not ever have sexual intercourse, 63 (77.8%) were female, and only 18 (22.2%) were male.
We assessed the relationship with the variable of “have you ever had sexual intercourse” with sociodemographic characteristics including gender, education, working for pay, income and found an association with income and education (p=0.001). There was also a significant relationship between age and having sex (age of those who never had sex was 20.23±3.35 versus those who did (23.82 ±6.98, Mann Whitney U test, P=0.001). Also, the level of STD/HIV knowledge and the score of sexual attitudes were statistically significantly lower in the students who never had sex than those with sex (P<0.001) (Table 2).
Univariate logistic regression analysis was conducted to estimate the association between sex and sociodemographic characteristics which was consistent with bivariate analysis (Table 3). Multivariate logistic regression showed that those with sexual activity were 34% more likely to have a higher score of knowledge related to STD/HIV (95%CI 1.15-1.58). However, such individuals were 39% less likely to know condom use (95%CI 0.42-0.88).
Are the reasons for not having sex different between females and males?
Reasons for not having sex were shown in Table 4. Fears of pregnancy and HIV/AIDS, or other sexually transmitted diseases were the common reasons for not having sex. . But fear of pregnancy was the first reason for sexual abstinence in the female college students (P<0.01).These reasons were then compared between males and females (Table 5). Females were more likely to note that they did not have the opportunity to have sex (70.2% in female versus 29.8%, in male P=0.007). More females thought that sex before marriage is wrong (93.9% of females versus 6.1% in males, P=0.05, Fisher test.
The feeling of not ready to have sex
This statement was associated with education (P=0.05). There were 23.3% of graduates than 76.7% of undergraduates who did not have sex as they felt not ready for it. There was also an association between the total score of sexual attitudes and feeling of not ready to have sex (Applies: 39.90±3.75 versus Not applies: 42.66±3.44, P=0.05). More than 10% of students with income more than $1000 per month noted that they feel not ready for sex (versus 89.7% with income of $1000 per month or less, P=0.02).
I have not had the opportunity
This variable was not associated with any socio-demographic characteristics, scores of knowledge, attitude, and sexually risky behaviors.
Sex before marriage is wrong
Only 3.0% of the students with no religion thought that sex before marriage is wrong compared to 97.0% of those who had one type of faith (P=0.001). There was an association between the total score of sexual attitudes and this item (Applies: 38.22±3.95 versus Not applies: 42.84±3.27, P=0.05).
I am afraid of getting pregnant
There was an association between salary per month, and afraid of geeting pregnant. 79.3% of students with $1000 or less noted that they are afraid of getting pregnant compared to those with salary greater than $1000 per month (20.7%, P=0.009).
Afraid of getting HIV/AIDS or other STDs
Those who earned $1000 and lower were more likely to be afraid of sex due to STDs (83.1%) than those who earned more than $1000 per month (16.9%) P=0.003). We assessed the association between the total score of knowledge on STD and fear of getting HIV among those who did not have sex and those who did. The mean total score of knowledge was 4.79±1.67 in those who responded positively to the statement, compared to those who had sex (4.00±1.62) (P=0.001).
Overally, the prevalence of sexual abstinence was low among the university students. Sexual abstinence as a strategy to prevent the risky sexual behavior has been recommended and resulted in successes, especially in African countries (3, 8). Although the prevalence of sexual abstinence varies in different countries with different socio-cultural contexts, there is a typical pattern leading to a dramatic decline in the prevalence of sexual abstinence.
This high rate of sexual activity increases the risk of unwanted pregnancy, STIs, and adverse reproductive health outcomes in this young population (19, 20). Among developed countries, U.S. youth has the highest rate of sexually transmitted disease, and each year ten million new cases of sexually transmitted infections are detected among college-aged youth (21).
Wu et al. (2020) evaluated the trend of sexual abstinence in the United States women who were born between 1938 to 1983. The abstinence rate was 48-50% in women born in the late 1930s and early 1940s. This rate decreased to 9-12% in women born between the late 1940s and the early 1960s. One per nine never-married women who were born between the mid-1960s and the early 1980s have abstained. Alhassan and Dodoo (2020) reported sexual abstinence in one-fifth of 235 never-married youth aged 20-24 years in poor urban Accra, Ghana (22). Similar to the finding of the present study, 76.7% of Portuguese college students, reported by Santos et al., were sexually active (2016) (2).
Based on the findings of the present study, among the students who never had sex, only 22% were males. Also, significant differences were seen in the reasons of sexual abstinence between males and females. This pattern was similar to that reported by other countries. Gender-based differences in the rate of abstaining sex and the primary reasons for sexual abstinence were reported previously. Kabiru and colleagues (2007) showed that female African youths have two times more desire to wait until marriage to initiate a sexual relationship. Also, fear of pregnancy was reported four times more in females than males for abstaining sex (23). Conversely, in Ghana, the prevalence of sexual abstinence is lower in girls than in boys (22% versus 26%) Due to financial problems in young girls (22).
In the present study, never having sex was significantly associated with age, STD/HIV knowledge, and condom knowledge. In line with the results of the current study, Oladepo et al. (2011) reported a higher rate of premarital sexual abstinence in younger Nigerian adolescence (24).
The study in sub-Saharan African countries showed more prevalent absenting sex in younger adolescents (23). Reduced parental control, influences of peers and media, and development of secondary sexual characteristics were reported as the potential causes of higher sexual relations in older adolescence (25-27). In four sub-Saharan African countries, abstainers were significantly younger than sexually active adolescents. Pre-puberty-based abstinence interventions in young girls and boys whose sexual identity is still evolving can be more effective than older ages (23).
Higher knowledge about STD/HIV and condom use can change individuals' attitudes from traditional beliefs to logical thinking and will lead to healthier sex. On the other hand, perhaps, little knowledge leads to the false power to handle sexual behavior with confidence and reduces fear of pregnancy and HIV/AIDS; two important reasons for sexual abstinence in adolescents noted in the literature (12, 28).
Three common motivations to avoid sex in this study were fears of pregnancy, HIV/AIDS, or other sexually transmitted infections, followed by not having the opportunity. A qualitative research by Long-Middleton et al. (2012) showed that readiness, fear, beliefs and values, partner worthiness, and lack of opportunity are the main reasons for sexual abstinence in young women (12). Patrick et al. stated that the values (Moral or ethical objections and religious belief), health (avoiding pregnancy and disease), and not being ready for sex (emotional readiness) were three motivations to avoid sex in adolescences (29).
In the present study, great pressure from others, particularly from friends, to have sexual intercourse was reported in male and female college students. Delay in the first relationship in adolescence with friends who believe in postponing a sexual relationship has already been reported (30, 31). Wana (2019) reported that peer pressure is the essential factor associated with high-risk sexual behavior among Ethiopian school adolescents (32). Kreager and Staff (2009) also reported that more significant numbers of sexual partners positively correlate with men's peer acceptance and negatively correlate with females' peer acceptance (33).
The present study has revealed that lower income has a significant association with not being ready for a sexual relationship, being afraid of pregnancy, and HIV infection, although this pattern was opposite of what was reported in low-income countries (34).
This study had some limitations. Self-reporting sexual behaviors may be a source of bias and lead to over-or underreport by the students who would like to boost or hide their sexual activities, which was also reported as a limitation in the studies of others (35, 36). Also, we focused on vaginal sex and intercourse. Other sexual relationships may have different patterns. The strength of this study was a relatively large sample size. Moreover, the anonymous nature of the research and using an online method to collect information could increase the validity of the results.
Despite the critical role of sexual relations in human development, the high rate of sexual activity, especially in male university students, leads to higher risk of unwanted pregnancy and sexually transmitted diseases. University students should be educated about the healthy activities, and the interventions are needed to improve students' sexual behavior. To understand the reasons behind sexual abstinence, we should learn the mechanism by which decisions are made surrounding sexual activity and plan accordingly to promote adolescent health.
This article is original and was not published in any other journal. All authors have read and actively participated in the analysis, and writing up the manuscript, and consented to publications. The IRB committee of the university approved this study. All student information was kept confidential. Students completed and submitted forms if they consented to participate in the study.
Conflicts of interest
Authors declared no conflicts of interest.