Introduction

Sexual and reproductive health (SRH) refers to a state of physical, emotional, mental, and social well-being in relation to all aspects of sexuality and reproduction, not merely the absence of disease, dysfunction, or infirmity (Zhang, 2008). China has experienced dramatic social and cultural change owing to its economic reform and opening-up policy since 1980, and sexual attitudes and behaviors of the Chinese population have thus changed dramatically. SRH issues such as premarital sex, unplanned pregnancies, induced abortion, HIV infection, and sexual abuse have become important public health issues in China. SRH issues of particular groups such as rural-to-urban migrants and rural residents deserve greater concern and further research.

This article provides an overview of the SRH situation in China. Based on the World Health Organization’s (WHO) Operational Framework on Sexual Health and Its Linkages to Reproductive Health (World Health Organization, 2017), the topics of comprehensive education and information regarding SRH; fertility care services and utilization; sexual behavior; contraception; pregnancy and antenatal, intrapartum, and postnatal care; induced abortion; sexual transmission of HIV-AIDS; and gender-based violence and sexual abuse are included in this article. Future perspectives on SRH in China are also considered.

Methods

A comprehensive literature search of publications on SRH issues currently in China was conducted. Due to the authors’ language literacy, articles written in English and Chinese were included. Databases used for searching included PubMed, Scopus, and China National Knowledge Infrastructure (CNKI). Keywords used in Scopus included “reproductive health,” “reproductive behavior,” “sexual health,” “sexual behavior,” “contraception,” “illegitimacy,” “unmarried mother,” “unmarried father,” “abortion,” “HIV,” “acquired immunodeficiency syndrome,” “gender-based violence,” “sexual child abuse,” “sex offense,” “China,” and “Chinese.” Relevant Medical Subject Headings (MeSH) terms were used for searching in PubMed, including “reproductive health,” “reproductive behavior,” “sexual health,” “sexual behavior,” “contraception,” “illegitimacy,” “abortion, induced,” “HIV,” “acquired immunodeficiency syndrome,” “child abuse, sexual,” “sex offenses,” “China,” and “Chinese.” Two researchers independently searched and reviewed the literature. A total number of 12,348 articles (including journal articles, conference papers, and correspondence) published from 2005 to the present (April 14, 2021) was found. After screening the titles and abstracts for relevance, 84 articles were used in this article. Results were organized following the WHO Operational Framework on Sexual Health and Its Linkages to Reproductive Health (World Health Organization, 2017), and are described here.

Comprehensive SRH Education and Information

In China, education regarding maternal and child health care and family planning is mainly provided for married couples of childbearing age. However, education on SRH for adolescents, migrants, and rural populations has been neglected. Adolescents in China have had unsystematic and incomplete knowledge of sexual health. According to the first National Youth Reproductive Health Survey in 2009, adolescents’ knowledge of the modes of HIV transmission was unsatisfactory (Zheng & Chen, 2010). Misunderstandings about the transmission routes of HIV had been identified in the survey: 48.4% and 57.4% of the subjects considered sharing food in daily life and mosquito biting as transmission routes, respectively (Chen et al., 2012). A cross-sectional survey conducted in 2017 among 1,840 senior high school students and university students from 11 provinces and municipalities demonstrated that the average score of SRH knowledge was merely 58.56 out of 100, and only 53% scored 60 and above. Girls’ score was higher than boys’ in senior high school, while the opposite was true in college (Zhao et al., 2019). Although 62.4–69% of senior middle school students had knowledge of puberty hygiene, less than 42% of them knew about reproduction or contraception (Jia & Wang, 2015). Similarly, a study in seven cities revealed that knowledge about sex physiology and contraception among college students was satisfactory (Shu et al., 2016).

With the acceleration of the social economy and urbanization, the population of migrants has been increasing in China, and migrants’ SRH knowledge appears to be a critical issue. In general, migrants lacked knowledge of contraception, reproductive tract infections, HIV-AIDS, and so on. A study reported that only 11% of male migrants and 30% of female migrants in Beijing knew the exact time of the ovulatory period (Wang et al., 2016). Another study reported that 76% of female migrants did not know emergency contraceptive methods, and 64% had never received education on contraception. Construction migrants lacked knowledge of HIV-AIDS, as a study in Chengdu demonstrated that only 29% of construction workers correctly answered questions regarding the non-transmission routes of HIV-AIDS (Wu, 2010).

A study among 5,443 country dwellers in 84 villages in Gansu, Qinghai, Shanxi, and Xinjiang found that rural residents had scant SRH knowledge. Totals of 64% unmarried women, 56% married women, 70% unmarried men, and 72% married men knew nothing about routes of reproductive tract infections. Among respondents who knew at least one symptom of reproductive tract infections, men had better knowledge than women (Zhang et al., 2013).

Fertility Care Services and Utilization

Since 1994, the focus of fertility care services in China has shifted from family planning alone to integration with other services. First, the family planning service has changed from birth control to people-centered care. Programs on enhancing the services of contraception and prevention of reproductive tract infections have been successfully carried out. Second, reproductive tract infections, including HIV infection, have changed from a silent culture to a heated issue. It was advised that HIV prevention be incorporated with family planning services to maximize health benefits. Third, abortion can lead to multiple complications such as hemorrhage, infection, and cervical damage. A program entitled Medium- and Long-Term Development Program for Young People (14–35 Years) was developed by the Chinese government in 2017 for unmarried young women to help reduce unwanted pregnancies and induced abortions (Liu et al., 2019; Tan et al., 2019). In addition, safe abortion services and postabortion care have been included as discussion topics at the International Conference on Population and Development (ICPD) and the Beijing Platform for Action to address the health needs of women. Despite these achievements, fertility care services were mainly available in large cities and urban areas; services for migrants, rural residents, the disabled, and the elderly needed to be strengthened.

The utilization of fertility care services among adolescents and rural-to-urban migrants was insufficient. A survey among 1,305 university students in Guangzhou demonstrated that dysmenorrhea was the main problem among female students, accounting for 54% in the 15- to 19-year-old group and 57% in the 20- to 24-year-old group. However, 61% and 56% in the 15–19 group and 20–24 group did not have any treatment for this symptom, respectively. Phimosis was the main problem among male students, accounting for 12% in the 15- to 19-year-old group and 9% in the 20- to 24-year-old group (Ma et al., 2018). There were also huge unmet needs for contraception among adolescents and unmarried youths, which resulted in high and repeat abortion rates (Fang, 2015). Even worse, owing to shame and cost, adolescents were likely to choose unsafe abortion (Fan et al., 2014). According to these results, more attention to and investment in services for adolescents are needed.

It was reported that rural-to-urban migrants at reproductive ages still did not have equal access to fertility care services (Fang, 2015). Fear of criticism and discrimination, high medical costs, long waiting times for seeing a doctor, and a lack of health policies in the workplace were the reasons preventing female migrants from seeking timely medical care (Su et al., 2014). Luo et al. (2015) found that 92.5% of migrant women in Ningbo desired reproductive knowledge. Counseling for the prevention and treatment of common reproductive diseases, sexual, physiological, and mental health, and contraceptive practices were expected by the migrants (Luo et al., 2015). Female migrants in Shenzhen received SRH services in maternal and child health care, reproductive health checkups, eugenics, contraceptive use, and reproductive tract infections. However, significant differences in the reception of services existed between married and unmarried women. The utilization of services was generally lower among unmarried than married female migrants. There were 52% and 40% of married and unmarried female migrants who received eugenics counseling, respectively.

Sexual Behavior

Premarital sex has been increasingly accepted by young people in China, as a majority of youths considered it fine to have premarital sex if they were willing to or had intended to get married. According to the first National Youth Reproductive Health Survey in 2009, 22.4% of respondents aged 15–24 had experienced premarital sexual intercourse (Zheng & Chen, 2010). Adolescents who were older, in higher grades, and male were more likely to have sexual intercourse than their counterparts. Premarital sexual intercourse was more prevalent among out of school youths than among in school youths, especially among the jobless (65.24%). Youths living in developed, coastal, and urban cities had a higher prevalence of sexual intercourse than those living in developing, inland, and rural cities (Cheng, 2015). Age of first sexual intercourse was an important indicator of unplanned pregnancies. A review showed that the earliest age of sexual intercourse was 12 years (Li et al., 2014; Lian et al., 2015), and the average age of first sexual intercourse ranged between 16.3 and 22.8 years (Guo et al., 2012; Shu et al., 2016; Zhang et al., 2013).

Risk-taking sexual behaviors included multiple partners, casual and commercial sex, and having sex after drinking alcohol. Youths were more inclined to have at-risk sexual behaviors (Ding et al., 2018). A survey of students in Yunnan found that 22.6% of males had more than one partner, a rate almost twice as high as that of females. Among 43 males who had anal sex with other males in the recent one year, 21 (48.3%) had commercial sex (Cai et al., 2017). A survey among students in 11 provinces revealed that a higher proportion of senior school students than college students having sexual behavior called someone for sex after alcohol drinking (Zhao et al., 2019). A recent internet-based survey among 53,508 youths aged 15–24 demonstrated that risk-taking sexual behaviors, such as having intercourse for the first time without using a condom, were more prevalent among those who had a lower socioeconomic status and came from families with open attitudes (Zou et al., 2021).

Migrants were vulnerable to unsafe sexual behaviors because of their low education level, poor living conditions, insufficient knowledge of SRH, poor awareness of SRH risks, and poor self-protection skills regarding SRH issues (He et al., 2012). Moreover, when they were exposed to a new environment, the likelihood of having unstable sexual partners, commercial sex, and alcohol drinking increased. A comparative analysis in Shanghai revealed that premarital sex was high among female migrants (Wang et al., 2013). A study in Changzhou found that the average age of first sexual intercourse among migrant females was 19, and 72% had their first sexual experience after migration. Owing to ineffective methods of contraception, unintended pregnancies and abortions were common (Zong et al., 2021). Therefore, SRH education and related services for migrants should be increased.

Contraception

Contraception is the intentional prevention of pregnancy by artificial or natural means. According to the World Bank (2021) Data, the contraceptive practice rate of women aged 15–49 was 83.8% in 2000 and 87.9% in 2012, which was higher than the global figure in 2000 (60.2%) and 2012 (63.3%). A meta-analysis among unmarried women in China demonstrated that 32.3% used contraceptive methods, and the most commonly used method was the condom (61.4%), followed by oral contraceptives, the rhythm method, and withdrawal (Wang et al., 2019). In comparison, the most frequently used contraceptive method among married women in China was long-acting reversible contraceptives, particularly intrauterine devices (Long et al., 2016).

The first National Youth Reproductive Health Survey found that over 50% of youths did not use any contraceptive method during their first sexual intercourse, and over 21% did not use contraception during their most recent sexual experience. The results suggested that youths engaged in unsafe sex and faced the risk of HIV infection and unplanned pregnancy (Zheng & Chen, 2010). A survey (N = 78,400) conducted in seven cities found that fewer women (50.54%) than men (57.10%) used contraceptive methods during their first sexual act (Shu et al., 2016). In the choice of contraceptive methods, the condom accounted for 61% of usage in the first sexual behavior and 71% of usage in the most recent sexual activity, whereas about 15% of youths used traditional practices of withdrawal and the rhythm method in their most recent sexual behavior (Zheng & Chen, 2010). A survey among 1,305 university students in Guangzhou indicated that 57% used contraceptive methods, and the reasons given for not using contraception were that contraception was considered unnecessary, intercourse was within a secure period, the partners were gay, there were partner disagreements, and so on (Ma et al., 2018). Students in casual relationships were less likely to be fully consistent with contraceptive usage than those in steady relationships (Shu et al., 2016).

Pregnancy and Antenatal, Intrapartum, and Postnatal Care

Pregnancy is a special period for women, which can cause great physical and psychological changes and a variety of health issues. A small proportion (about 22.4%–30%) of pregnant women had their first antenatal examination during the first trimester (Hu et al., 2014; Song et al., 2019), indicating that pregnant women did not pay enough attention to critical early pregnancy health care. In these studies, more than 60% of pregnant women had four times or more antenatal examinations (Hu et al., 2014; Song et al., 2019). However, the examination items were not standardized enough to meet the requirements of maternal health management services standards (Song et al., 2019). The place of residence was an important factor affecting prenatal care (Hu et al., 2014; Song et al., 2019). Women who lived in cities or near a medical institution were more likely to have antenatal checkups. A high level of prenatal care knowledge could increase the antenatal examination rate (Hu et al., 2014; Song et al., 2019). Besides, women who had a history of adverse pregnancies were more concerned with antenatal care and had a stronger desire for a good pregnancy outcome; they had a higher awareness of using prenatal care services (Song et al., 2019).

Unmarried adolescent pregnancies has become a social issue (Huang, 2016). A total of 10%–50% of unmarried young people reported having become pregnant or having impregnated their sex partners (Guo et al., 2012; Hu et al., 2015; Ning et al., 2015; Zhou et al., 2012). The unplanned pregnancy rate among Chinese college students was approximately 34%, which was higher than that in other countries. The fertility rate among Chinese girls aged 15–19 had increased from 6.0 births per 1,000 individuals in 2000 to 9.2 births per 1,000 individuals in 2015, which can be attributed to increased sexual activity and low contraceptive use (Luo et al., 2020). Factors associated with unmarried pregnancy included women’s low level of education (Guo et al., 2019; Qian & Jin, 2020; Yu et al., 2010), low economic status (Guo et al., 2019), a low level of SRH knowledge (Huang, 2016; Yu et al., 2010), women being migrants (Li & Tian, 2017), living in non-Eastern regions (Guo et al., 2019), living in rural areas (Luo et al., 2020), living in provinces with a high minority population density, lower GDP per capita, a high ratio of males to females (Luo et al., 2020; Wang & Qiao, 2020), women having multiple sexual partners, adverse childhood experiences (Li & Tian, 2017), having the first sexual intercourse at an early age (Huang, 2016; Shu et al., 2016), women smoking, alcohol drinking (Guo et al., 2019), and having an introversive personality (Wei et al., 2008; Yu et al., 2010).

Unmarried pregnancy can lead to adverse physical and psychological outcomes (Huang, 2016). Unmarried young women are immature and do not always realize they are pregnant until the second trimester. The majority of unmarried pregnancies were terminated by induced abortion. Both continuing the pregnancy and aborting it could lead to complications that cause irreparable harm to women’s health. Moreover, unmarried women, especially adolescents, might experience serious anxiety and fear when they are pregnant (Huang, 2016). Because of shame and worry, most of them do not seek help from family or health care professionals (Hu et al., 2010). In addition, pregnant women could face economic and social difficulties (Huang, 2016; Wang & Qiao, 2020). Therefore, it is necessary to ensure girls’ sex education and provide adequate SRH services for those who are sexually active, and to reduce unmarried pregnancy and childbearing.

Induced Abortion

According to the China Statistical Yearbook, between 2005 and 2017, the average number of induced abortions per year in China was 7,845,900. The rate of induced abortion increased from 2005 to 2008, remained steady between 2009 and 2013, then rose again to the highest point in 2016 (28.13‰), and declined slightly in 2017 (Tan et al., 2019). These published data were estimated to be lower than the actual rate.

Clinical data demonstrated that the number of abortions implemented among unmarried young women was increasing annually, accounting for a little more than 50% of the total number (Xiao et al., 2015). Unmarried women aged 20–24 were the main group (30%) receiving induced abortion, while the proportion of youths below 20 years was increasing (Xiao et al., 2015; Zhang & Lu, 2015). Among unmarried females aged 15–24, 82.5% of pregnancies ended in induced abortions (Guo et al., 2019). Moreover, there was a high rate (about 30%–60%) of repeat abortions among youths who had induced abortions (Chen et al., 2018; Li, 2013; Pan et al., 2012; Qin et al., 2018; Wang et al., 2013, 2015). Factors associated with youth abortions included a lack of or failed contraception, multiple sexual partners, and an early age of first sexual intercourse (Feng et al., 2011; Gao et al., 2017; Liu et al., 2015).

Compared with unmarried young women and adolescents, there were fewer studies investigating abortions among married women. Studies on abortion among married women focused on certain regions and groups, and the abortion status varied across different populations. A study among the migrant population in Guangdong reported that the rate of abortion was 47% and the repeat abortion rate was over 80% (Gui et al., 2019). The rate of abortion in rural China was 32.0%, and the repeat abortion rate was 23%–34% (Li, 2017; Lin et al., 2014). In rural China, married women were the major population receiving abortions, the root cause of abortion being unintended pregnancy. Lin et al. (2014) revealed that the main reasons for abortion included medical reasons (meaning that pregnancy would damage the woman’s health or even endanger her life) and complying with the one-child policy of China (Lin et al., 2014). As a result, appropriate contraceptive methods should be provided to families.

Sexual Transmission of HIV-AIDS

The incidence of HIV-AIDS was high in western and southern China and low in eastern and northern China. The incidence of HIV-AIDS was high in southwest China and Xinjiang (Wang et al., 2019). Sexual transmission was the main route of HIV transmission. According to the National Health Commission, by the end of October 2019, 958,000 people were reported to be infected with HIV. From January to October 2019, a total of 131,000 new infections were reported, contributed by 74% heterosexual transmissions and 23% male homosexual transmissions (He, 2019). The number of infected men (75%–88%) was much greater than infected women (Che et al., 2019; Gui et al., 2019) and most males were infected through sex (Che et al., 2019; Gui et al., 2019). The elderly accounted for about 30% of the infected population (Gui et al., 2019). The increasing number of infected elderly males was a remarkable feature in China (He, 2019). The majority of HIV-infected males who had sex with men were aged 20–49, well-educated, and unmarried (Chen et al., 2019; Liu et al., 2019; Zhang et al., 2019). From 2011 to 2015, new cases of HIV among Chinese students aged 15–24 increased by an annual average of 35% (Burki, 2018). Youths aged 15–24 accounted for 11%–23% of the infected population, with a larger number of males than females. The major transmission route was homosexual transmission (51%–84%). About 32%–40% of cases were found by consulting and detecting (Da et al., 2018; Fan & Qin, 2017; Li et al., 2017; Liu et al., 2016; Xu et al., 2018).

Gender-Based Violence and Sexual Abuse

Gender-based violence includes acts that inflict physical, mental, or sexual harm or suffering, threats of such acts, coercion, and other deprivations of liberty (Maquibar et al., 2018). Such violence may be detrimental to one’s physical and psychological well-being (Zhang et al., 2016). There has been a preference for sons over daughters in China since ancient times and gender inequality still exists in Chinese society, which can lead to gender-based violence against women. Among unmarried women seeking an abortion, 12% suffered forced sexual intercourse (Feng et al., 2011) and 15% experienced nonconsensual sexual intercourse in their first experience (Wang et al., 2013). Totals of 9% and 0.5% of women experienced verbal and physical coercion, respectively. A study among female college students revealed that the prevalence of contact sexual abuse and noncontact sexual abuse were 10% and 15%, respectively (Su et al., 2008).

Intimate partner violence (IPV) usually occurred in intimate relationships such as marriage or cohabitation and included sexual violence. Women may be more submissive in sexual interaction than men (Zuo et al., 2018) and were more likely to suffer from IPV. A study reported the prevalence of sexual IPV among female participants was 1.8% (Decker et al., 2014).

Behaviors related to gender-based violence, sexual violence, sexual coercion, or nonconsensual sex included unwanted penetrative sex, attempted rape, unwanted touch, noncontact forms of abuse such as verbal harassment or forced viewing of pornography, as well as exchange or transactional sex. These acts might be experienced in many forms through physical force as well as threats, intimidation, emotional manipulation, deception, blackmail, and material and nonmaterial incentives (Guo et al., 2014). Such abuse and violence could happen in any relationship and cause serious harm to the victim’s physical and mental health. Influenced by traditional Chinese attitudes, many victims were afraid to seek help or counseling, which could result in further anxiety, depression, and other adverse psychological reactions (Chen et al., 2014). Legal and regulatory measures should be taken to reduce the occurrence of sexual abuse. The safety of service providers should also be improved (Rong, 2020).

Children generally have no knowledge about sex and thus are more vulnerable to sexual abuse. Child sexual abuse (CSA) is a critical social issue that seriously affects children’s health and development. Chen et al. (2014) showed that the prevalence of CSA was 15%–26% among girls, and 7%–15% of the CSA female victims reported contact sexual abuse; 11%–25% of boys reported CSA and 5%–15% of male CSA victims reported contact sexual abuse. A large-scale study conducted among senior school students revealed that the prevalence of CSA was 27.5%, including noncontact (17.1%), contact (7.8%), and penetrative CSA (2.5%) (Tang et al., 2018). Perpetrators were mainly men and a large proportion of them were friends, acquaintances, neighbors, and teachers who were related to the victims’ daily life (Chen et al., 2014; Sun et al., 2006; Tang et al., 2018). Children living in the cities were more likely to suffer from CSA than those in rural areas. Adverse family environments were an important risk factor in CSA victimization, such as parental absence, strained family relationships, and parental addictions (Chen et al., 2014).

Actions against gender-based violence have been taken by governmental and nongovernmental organizations and communities. Since 2015, 2,009 institutions have been developed by the Women’s Union in China and have helped and protected 9,200 women and children. Local organizations, communities, and legal sectors have collaborated to organize workshops and training sessions against all forms of gender-based violence (Rong, 2020). Care for girls’ actions was launched to ensure gender equality and prevent gender-based violence (Fang, 2015; Zhang, 2008). Nevertheless, services against gender-based violence were available mainly in large cities and urban areas and for women; services offered for migrants was still limited according to a recent survey among 108 organizations (Rong, 2020).

Research on SRH in China and Future Perspectives

Evidence-based research has been largely and successfully conducted to investigate SRH attitudes and behaviors, demands and the utilization of SRH services, service modes of SRH, and the effectiveness of the SRH interventions in China. However, there are areas that can be improved. First, most research was conducted in specific regions, limiting the generalizability of study results. Up-to-date national surveys on SRH are needed. Second, research on women empowerment was insufficient. Insights into women’s rights and how gender equality influences SRH need further investigation. Third, most SRH studies used quantitative methods involving questionnaires and sampling strategies. Experimental studies, literature reviews, and case studies might be taken into consideration. Narrative interviews could be useful to explore sexual beliefs and ethnic philosophies of certain populations (Guo, 2008). Finally, research on SRH has been focused on adolescents, but studies on other targets should be considered, including the elderly, the disabled, and homosexual populations.

For instance, there have been controversies regarding SRH among the elderly. Sexual dissatisfaction and dysfunction are common among menopausal women. A study found that Chinese women had less intimacy and less sexual intercourse after menopause (Lo & Kok, 2013). Vaginal dryness and insufficient lubrication made intercourse difficult (Jiang et al., 2020). Dissatisfaction in sexual life might be detrimental to couple relationships and increase the likelihood of male partners’ seeking extramarital affairs, commercial sex, and becoming infected with HIV-AIDS. Despite the bad consequences of sexual dissatisfaction and dysfunction among menopausal women, few sought help from health care providers. A study found that menopausal women in rural China lacked access to SRH services, including intrauterine device removal (Sun et al., 2015). Since the elderly population is increasing in China, the SRH of menopausal women deserves attention and further research.