The Acculturation of Sex and Health: An Asian American Dilemma

Lanjun Wang

Writer's comment: In his English 101 (Advanced Composition) class, Dr. Adam Sonstegard asked his students to write a 10-page paper on a topic of our choice. The acculturation of Asian American women and sexual health had interested me since winter break, and this assignment seemed the perfect way to jumpstart my research. As the statistics rolled out before me, I felt a great urgency for my female comrades. Although sexual health is a problem that is espe-cially suppressed for Asian American women, it is an issue for every woman, regardless of generation and cultural orientation. For my female Asian American readers, I hope my paper provides know-ledge that will aid you in making future choices; for everyone else, I hope you can reach out to the women in your lives and give them the information and support that they need for a healthier life. I would like to thank Dr. Sonstegard for his encouragement, and for introducing me to the many on-campus resources that were so crucial for my research. My appreciation also goes to Tony Gragg, who has provided me with countless suggestions and insight over the year; and to Lisa Yamauchi and all my survey participants, who were most generous for taking the time to lend their words and angles on such an intimate topic.

—Lanjun Wang


Instructor's comment: Students in three of my writing courses this year read winning essays from previous editions of Prized Writing. We puzzled over these essays in class, used them as models for confronting common rhetorical challenges, and noted each writer’s personal stake in the chosen topic. As long as my students followed the patterns—and took their cues—from these winning essays, I allowed them to write on any subject. Lanjun Wang, for one, saw a need for an essay exploring Asian Americans’ reluctance to talk about reproductive health care. She circulated questionnaires, interviewed nurses, and documented just how hesitant young Asian women were to ask for help, how little they knew, and how badly many of them might have needed the information. Then, she not only revised the essay with the two workshop partners I had as-signed to her in class, but sought out two additional classmates to read and help her revise her work. Her examination of one local community’s silence toward sensitive subjects could spark fascinat-ing discussions in the families of many UC Davis students. Her essay demonstrates what can happen when teachers use Prized Writing to encourage students to generate prized writing of their own.

—Adam Sonstegard, University Writing Program

The great weight of parental expectations is perhaps one of the most common themes in the lives of Asian American women. From a young age, we are aware of our parents’ vision for our lives. We knew what we should study, how we should act, whom we should eventually marry. . . . Even if we fail to do what was expected of us, we are always aware of the tension between parental approval and personal choice.
—Claire S. Chow, Leaving Deep Water: The Lives of Asian American Women at the Crossroads of Two Cultures

Unmentioned above are perhaps the two personal issues causing the greatest parent-child dissonance of all: premarital sexuality and reproductive health. In the majority of today’s societies, sex is considered as the most private form of inti-macy; and Asian cultures, which have traditionally been highly patriarchal and sexually restrictive, continue to view sex as taboo (Okazaki, 2002). As a consequence, Asians tend to avoid—or be disinterested in—receiving proper reproductive health services. Research has repeatedly shown that as a group, Asian American women seek both sexual or reproduc-tive health services and screening services at a significantly lower rate than non-Asian American women (Tu, Taplin, Bar-low, & Boyko, 1999; National Asian Women‘s Health Organi-zation, 1997). However, research also shows a positive corre-lation between the level of acculturation of Asian American women and the likelihood they will seek sexual health services: as new generations become increasingly acculturated, more Asian American women are taking clinical reproductive health measures (Okazaki, 2002). The relationship between sexual health and culture is a factor for millions of Asian Americans nationwide, and presumably also for the thousands of Asian American students at UC Davis. As of 2004, close to 33% of the undergraduate student population are Asian American (UC Davis, “Ethnicity”), and almost 55% of all students are female (UC Davis, “Gender”); thus this is an issue that potentially affects a large segment of the UC Davis population. The purpose of my study is to determine whether past findings on acculturation and sexual health apply to the Asian American undergraduate women at UC Davis.

The participants of this study consisted of 20 female Asian American undergraduate students at UC Davis. Undergra-duates were selected for their relatively young age and their tendency to be involved in casual relationships. As many tradi-tional Asian families remain closed to the idea of premarital sexual activity, this age group marks a critical period: although young women are not under immediate parental surveillance, they have not yet received parental consent to sexual auton-omy. Thus, while they are able to make decisions about their sexual lives, the Asian-American women of this group are still bound by their incomplete independence from their parents. Participants were primarily of Chinese, Vietnamese, Korean, and Cambodian national origins, with a small number of stu-dents identified as multi-ethnic or multi-cultural (i.e., with par-ents of differing cultures and/or nationalities). Students filled out a survey providing 1) demographic information, 2) ratings of parental, personal, and cultural attitudes towards premarital sex, and 3) self reports on sexual history and health measures. Of the 58 surveys passed out, 20 undergraduates returned completed surveys. Approximately 84 percent of the respondents were first generation Asian Americans; of these ~58 percent were freshmen, ~53 percent were Chinese, and 50 percent of all respondents were sexually active.

Asian Culture and Asian Americans
Research shows that in the majority of Asian cultures, sex is directly associated with reproduction in a family setting. Open discussion about sex is highly taboo, and sexual material has traditionally been limited to “religious or fictional texts,” such as the Kama Sutra (Gupta, 1994). Perhaps unsurprisingly, the patriarchal nature of Asian cultures enforces sexual restrictions especially strictly on women, whose public sexual disclosures and “open expression would represent a threat to the highly interdependent social order as well as to the integrity of the family” (Okazaki, 2002). Although most Asian cultures discourage sexual discussion and disclosure, each enforces this negative attitude through different beliefs and social insti-tutions. For instance, traditional Cambodian attitudes con-cerning sexuality and premarital sex center around the impor-tance of preserving “family honor” (Kulig, 1994), whereas tradi-tional Filipino attitudes are strongly influenced by Catholicism (Tiongson, 1997). In the United States, despite being heavily stereotyped by the dominant White American culture, Asian Americans remain a heterogeneous group, consisting of a va-riety of independent traditional and cultural attitudes. However, according to a 2002 study published in the Journal of Sex Re-search, group members still share a number of “Asian cultural characteristics,” such as the “primacy of the family,” “emphasis on propriety and social codes,” and “the appropriation of sex-uality” only after marriage (Okazaki, 2002).
      The results of my study confirm the researchers’ conclu-sions. Students participating in the surveys rated (on a scale of 1–5) both their culture’s and parents’ attitudes towards prema-rital sex on an average of 1.94 (not open at all—very negative); ~64 percent gave a rating of 1 or 2. Although, on average, students rated their personal attitude towards premarital sex as ~2.63, so were not as negative as their parents and culture in general, the data suggest a generally negative attitude among the participants towards the subject of premarital sexual activity. Not surprisingly, results showed a very low rate of parent-child discussions concerning sex (~1.79) and a rela-tively low level of comfort when engaging in such discussions (~2.16). Given these statistics, it was not surprising that over 80 percent of respondents asserted that they had learned about sex and its risks (e.g., sexually transmitted diseases [STDs]) from discussions with friends, high school sex education, and personal experiences rather than from speaking with parents. A first generation Chinese student wrote, “I never really discussed any information concerning sex and relationships. My parents are pretty traditional with their culture, [and] prefer that I do not pursue any relationships (i.e., boyfriends) until I graduate from college” (original emphasis). She went on to say that she had chosen to “hide” her relationships from her parents because she did not want to “disobey,” “disrespect,” or “disappoint” them in “any way.” The students’ ratings and self reports suggest they have, on average, remained consistent with the stereotypical cultural generalizations: that their parents and native culture are antagonistic towards premarital sex, that they rarely have sex-based discussions with their parents, and that when they do, they generally experience relatively high levels of discomfort because of their psychological struggles with parental disapproval and disappointment.

Asian Culture, Sexuality, and Health
Closely related to the issue of “sexual propriety” is the extent to which Asians are generally open to sexual health practices, such as Pap smears, pelvic examinations, and STD testing on an individual and familial basis. A survey conducted by the Na-tional Asian Women’s Health Organization (NAWHO) in 1996 reported that half of the Asian American women from six Cali-fornia counties had not “visited a healthcare provider within the last year for reproductive or sexual health services,” and that “one fourth had never received any reproductive or sexual health information in their lives” (Nowrojee and Silliman, 74; NAWHO, 1997). Many Asian American women feel that by following their cultural guidelines for sexual activity (e.g. within a heterosexual marriage and for the sake of reproduction), they are not at risk for sex-related consequences other than pregnancy (Nowrojee and Silliman, 77).
      Student survey responses do in fact suggest that this is accurate, even for recent generations of Asian American women. Although one participant believed that it was neces-sary to seek reproductive health services “at least once or twice a year, just to get a check up,” she herself after being sexually active for one year had never received reproductive health services because she “didn’t feel it was necessary,” and up until participating in the survey, had “never thought about it.” Similarly, several participants indicated that reproductive services such as Pap smears and pelvic exams were only ne-cessary when “switching partners” and because “college men and women tend to have multiple partners.” One of the partic-ipants claimed that because she was “monogamous,” she does not think that she will “have a problem.” These personal statements correspond to the common perception that only when individuals break away from a single, monogamous rela-tionship do they find themselves at risk of infection or health problems.
      Stemming from traditional expectations is a stigma to-wards those who contract STDs or other forms of reproductive health problems, as they are often associated with improper sexual activity and shame. Thus, the sexually repressive na-ture of Asian cultures dissuades many Asian American young women from undertaking reproductive health services by making them fearful of personal disclosure and a lack of con-fidentiality on the health provider’s part. Lisa Yamauchi, a Japanese American Family Nurse Practitioner at the Cowell Student Health Center (CSHC) at UC Davis, has had twenty years of experience in female reproductive health services around the Davis-Sacramento area, where she has worked in both private and campus clinics. When I asked her about this issue of confidentiality, Yamauchi asserted that although she does not feel this issue of privacy pertains exclusively to Asian Americans, she does believe that sexuality is under-discussed in Asian American families, and that “it would be a disgrace to the family if the family knew that they were having sex before marriage or coming in for STD screening because they have multiple partners.” Yamauchi went on to say that in some other cultures, parents may be more open in their discussion con-cerning reproductive measures, such as instructing their daughters to obtain birth control pills from Planned Parenthood at age sixteen. A first generation Vietnamese respondent spe-cifically addressed this question of confidentiality, stating that although she felt that any method of obtaining reproductive health services can be beneficial, she would “feel more com-fortable going to a confidential clinic than to [her] family doc-tor.”
      Although my participants made different choices, a gener-al trend was evident in their attitude towards parental influence on sex: although participants value their parents’ concerns and beliefs, parental opinions do not necessarily influence their decisions about sex. Many young women reported that sex is a very personal decision for which they are ready to take on the consequences, and others wrote that their respect for parental values extends beyond the issue of premarital sex and into other spheres of their lives. However, it is important to note that there is some statistical variability between those who are sexually active and those who have remained abstinent. On average, students who gave higher ratings for the importance and influence of parental opinions towards sex, level of personal agreement with parental opinions, and feelings of interconnectedness between personal decisions and family reputation/well-being have remained sexually abstinent.

Table 1

Pap smears and Pelvic Exams: What are they?
According to both my own respondents and researchers No-wrojee and Silliman, many Asian American women do not know what a Pap smear or pelvic examination is. The cultural-ly-embedded notion that sex “is only linked to reproduction” inevitably leads to a “failure to seek out broader health infor-mation and services for STDs, including HIV/AIDS, basic gy-necology care, and sexuality education” (Nowrojee and Silli-man, 78). Similarly, some participants reported that they did not have adequate knowledge about certain reproductive health services, such as the Pap smear. In our interview, Ya-mauchi also mentioned that because reproductive health ser-vices may be unavailable in some Asian countries, parents are unable to adequately inform their children of these healthcare options. “Women either have a fear of the Pap smear or are not aware of the importance of having one,” she said. “Some of the women who have come from China, they just don’t do screening like that. They don’t do mammography screening and Pap smears in some of the rural cities that their families have come from, and so through the generations, it hasn’t been passed on as something that’s as important.” According to Kaiser Permanente, the Pap test is used to screen women against cervical cancer. During the examina-tion, women are asked to lie on an examination table with their legs supported by stirrups, which raises a woman’s legs and allows a certified health professional to examine the vagina and genital area. The examiner will use a lubricated vaginal speculum to ease the vaginal walls apart before taking small samples of cells from the surface of the cervix using a cotton swab, brush, or a small spatula. The samples are then smeared onto slides (Pap smear) or mixed in a liquid fixative before being examined under microscopes in the laboratory. Women may feel uncomfortable when the speculum is inserted and/or when the examiner is taking cervical scrapings, but the discomfort can decrease if both the examiner and the woman are relaxed (Payne, “Pap Test”).
      Unlike the Pap test, pelvic examinations include both ex-ternal and internal examination of a woman’s reproductive or-gans. According to Kaiser Permanente, a typical pelvic ex-amination may consist of four components: 1) An external examination of the vulva (i.e., the area and structures sur-rounding the vagina, including the clitoris, labia, and urethral opening); 2) an internal examination of the vagina and repro-ductive organs, which may include a Pap smear and an STD test; 3) a bimanual internal examination during which the ex-aminer inserts two lubricated and gloved fingers into the vagina while pressing on the abdomen, and occasionally 4) a rec-tovaginal examination during which the examiner “inserts the lubricated first finger of one hand into the vagina, and the second finger of the same hand into the rectum,” while also pressing on the abdomen. Some women may feel slight pain during the bimanual examination as the health professional physically feels the ovaries, and in some cases, women may feel sensations suggesting bowel movement when the health professional extracts his/her finger from the rectum during the rectovaginal examination. This is completely normal, and will only last a few seconds (Payne, “Pelvic Examination”).

Asian American Acculturation, Sexuality, and Health
Some research has indicated that Asian American sexual conservatism has eroded with increasing exposure to the more sexually open American ideology (Okazaki, 2002). Results show that as younger generations become increasingly accul-turated into the White American culture, Asian American youths show a decrease in both guilty thoughts and feelings about sexual activity (Abramson and Imai-Marquez, 1982) and an increase in “premarital sexual intercourse” in college. What is particularly interesting is that Asian Americans who “consis-tently” date “White Americans” have “more sexual experience than those dating only Asian Americans” (Huang and Uba, 1992), and that Asian American high school students who speak English as their primary language are more likely to be “non-virgins” than other Asian American peers (Schuster, Bell, Nakajima, & Kanouse, 1998). It is hard to say whether a causal relationship exists between English-speaking Asian families, White American partners, and increased sexuality. However, these results may suggest that the Asian American youths who have primarily engaged in intimate relationships with White American individuals, or are from families who employ English as their primary mode of communication, may have reached a higher level of acculturation, thereby leading to higher rates of sexual activity.
      Judging from my study, sexual activity does seem to cor-relate with acculturation, as a greater percentage of second generation Asian American students (66.6%) are sexually ac-tive than first generation Asian American students (50%). Sexual activity aside, the data reveal some interesting trends and relationships in other areas of personal choice/attitude and parental influence as well. While both first and second generation Asian American students rated their parents’ atti-tudes and opinions towards premarital sex as fairly important (~3.43 and 3.75, respectively) and somewhat influential (~2.94 and 2.74, respectively), their self reported ratings for agree-ment with parental opinions on sex and connectedness be-tween personal choices and family well-being showed an in-teresting contradiction. Although first generation Asian Ameri-cans rated their agreement with their parents’ opinions (~3.25) lower than did their second generation counterparts (3.5), first generation Asian American young women reported that their personal choices were more strongly tied to their family’s rep-utation and well-being (3.75) than did second generation Asian American young women (3.5). When it comes to sexual and reproductive health services, the difference between genera-tions was more pronounced. Of the first generation students who were sexually active, only 38% had taken some sort of testing or screening, whereas in the second generation stu-dents, the percentage reached a whopping 100%.

With increasing exposure to Western, White American values, Asian American women face cultural dissonance with their parents. For many young women, growing up under a tradi-tionally sexually restrictive family atmosphere allowed them to internalize some of their parents’ values, which sometimes conflict with their newly acquired, more westernized attitudes. Researchers have found that with acculturation, Asian Ameri-cans become more likely to engage in premarital sexual activi-ties (Huang and Uba, 1992; Schuster, Bell, Nakajima, & Ka-nouse, 1998), and the present study suggests that alongside this increase in openness to sexuality, younger generations of Asian American women are—on average—also seeking re-productive health services more often.
      It is important to note that these conclusions were drawn from averaged ratings/generalizations provided by a small sample of UC Davis students, and do not necessarily apply equally to all Asian American women. However, results from both the current study and past research unveil an alarmingly low number of Asian American women who are knowledgea-ble about, and/or seeking, sexual and reproductive health ser-vices. Such disregard for receiving health services can lead to critical health problems, such as STDs, cervical and ovarian cancer, and infertility. Coupled with the effect of acculturation (i.e., greater rate of sexual activity in younger generations), this lack of knowledge places Asian American women at increased risk of reproductive health problems, and so it is increasingly critical to educate this population before they are endangered by the bind of tradition.


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