A qualitative study of the lived experiences of young Chinese females in condom use negotiations

Abstract

Based on a qualitative study of young Chinese females' lived experiences of condom use negotiations, this paper discusses how a gender and power perspective provides a new frame of reference in which to examine the shaping of young women's perception and decision-making regarding contraception. The recurrent themes of the narratives collected through individual interviews with 10 adolescent pregnant females living in Hong Kong indicate that their lack of bargaining power for sexual safety is maintained by the structures of social norms and their strong affective attachments to their partners. The findings facilitate practitioners' development of a multi-layered understanding of the power dynamics in sexual relationships and draw implications for further practice and research. Chinese cultural factors have also been explored in a contextual discussion on the influences of traditional gender roles on the constitution of adolescent sexual identities and sexual behaviours.

Keywords::

• young females
• condom use
• sexual behaviour
• power
• gender
• culture

Introduction

This paper examines the lived experiences of condom use negotiations among young Chinese females who experienced unplanned pregnancy in the Hong Kong context. The paper first reviews the conventional approaches in understanding the problem of unprotected sexual behaviour among adolescents and points out their limitations. Then it discusses how a gender and power perspective can be used to theorise a conceptual framework for analysing the power dynamics in condom use negotiations that shape the young females' perception and decision-making. It also takes cultural factors into consideration for a sensible discussion of young Chinese females' passive role in contraception.

This study focuses on the subject of condom use negotiations, which is important to adolescents' sexual and reproductive health as the male condom is still the most commonly used contraceptive method (Pulerwitz, Amaro, DeJong, & Gortmaker, 2002; Teitelman, Ratcliffe, Morales-Aleman, & Sullivan, 2008; The Family Planning Association of Hong Kong, 2006; Tschann, Adler, Millstein, Gurvey, & Ellen, 2002). Although there have been numerous discussions and even heated debates about the reasons for young females' engagement in unprotected sexual behaviour, most of the discourses focus on their lack of substantial knowledge regarding the dangers of unprotected sex, embarrassment about asking their partners to use condoms, fear of reduced sexual satisfaction and perceived sense of inconvenience (Arai, 2003; Ho & Wong, 2006; Thorsén, Aneblom, & Gemzell-Danielsson, 2006; Wingood & DiClemente, 2000). Other studies have examined the benefits and costs of condom use, proposing that when the estimated benefits of using condoms are higher than the expected costs, the chance that precautions are taken increases (Gebhardt, Kuyper, & Greunsven, 2003; Parsons, Halkitis, Bimbi, & Borkowski, 2000). The problem of condom use negotiations has also been analysed in the social learning framework, which is based on the assumption that protection of sexual behaviour is affected by the intention to avoid potential risks, the belief that the protection taken will be effective, and the knowledge of steps that must be taken to avoid risks (Amaro, 1995).

There are clear limitations to using conventional approaches to examine the phenomenon of unprotected sexual behaviour among young females. They fail to account for the different perspectives and behaviours of young males and females regarding safe sex (Gebhardt et al., 2003; Pettifor, Measham, Rees, & Padian, 2004). Moreover, based on an individualistic conceptualisation of sexuality, they ignore the ways in which gender-based power imbalances hinder women's ability to negotiate for their sexual safety (Pulerwitz et al., 2002; Pulerwitz, Gortmaker, & DeJong, 2000). Third, these approaches emphasise the rational side of taking precautions and propose that young people have not learned about the real dangers of unprotected sex, so by supplying adequate information and guidance it is expected that adults can help them make appropriate choices. However, sexual behaviour is often induced by the fulfilment of psychosocial needs. The strong desire for closeness and intimacy may reduce their awareness of and insistence on safe sex (de la Cuesta, 2001; Pistole, 1999). All these limitations indicate that research adopting a new conceptual framework of women's condom use negotiations is needed.

Some intellectuals incorporate gender and power perspectives to analyse women's sexual protective behaviour (Amaro, 1995; Blanc, 2001; Bowleg, Belgrave, & Reisen, 2000; Jewkes, Vundule, Maforah, & Jordaan, 2001; Pettifor et al., 2004; Tschann et al., 2002; Varga, 2003). The fundamental concern of gender identity is over the interrelated problems of self-recognition of his/her own gender and the recognition of his/her gender by other people. Issues of recognition are significant because they shape the way people of the same and different genders look at themselves and others, with varying degrees of solidarity, tension or even antagonism among them. There are two approaches to gender identity (Fox & Murry, 2000). The first approach treats gender as a social role, characterised by a distinct and well-integrated set of attitudes and behaviours. The second approach views gender as a social construct embodying cultural meanings of masculinity and femininity. It is personally created, interpersonally constructed, and broadly constituted by the social structures and ideologies of the wider social environment simultaneously. The social constructionist approach criticises that the conventional models of women's sexual protective behaviour are based on an individualistic conceptualisation of behaviour and fail to consider the broader cultural and social contexts of sexuality (Amaro, 1995). Researchers adopting a social constructionist approach heed the different effects of power on females' gender identity and decision-making in sexual relationships. In their views, the concept of power can link the micro-politics emerging in the negotiation of condom use and the macro-politics concerning the effects of the power structure of patriarchy on the formation and practices of current sex roles. Regarding micro-politics, recent research has investigated the degree to which women's sexual negotiation power influences their condom use consistency in sexual relationships (Blanc, 2001; Varga, 2003). The findings show that women's sexual negotiation power is likely to be compromised following early coital debuts, in relationships with older partners, and in casual sexual relationships (Gebhardt et al., 2003; Pettifor et al., 2004). The macro-political aspect reminds us that to truly understand women's sexual negotiation power, we must consider the social, political, economic and cultural forces that foster different power strategies among different groups of people. Relevant studies indicate that socio-demographic variables such as educational level, work status, class and ethnicity influence the degree of sexual negotiation power among women and men (Amaro, 1995; Arai, 2003; Bowleg et al., 2000). In fact, the micro-politics and macro-politics are inextricably interwoven and create a complex power network in which people's sexualities are expressed.

While research in the West has increasingly recognised the importance of adopting a gender and power perspective to analyse women's sexual protective behaviour, limited studies are available in Chinese societies. Therefore, the present study aims to provide a starting point for using this perspective to explore the experience of young Chinese females in condom use negotiations.

Recent research on the role of culture in sexual behaviour and sexual development has also led to an increased attention to the cultural factors affecting women's gender identities and sexual behaviours in general (Ho, 2008), and condom use negotiations particularly (Teitelman et al., 2008; To & Chu, 2009). Chinese cultural factors affect women's sexual protective behaviours in the following two ways. First, in Chinese culture, a person is perceived as the sum of the social roles they perform in society, and people believe there are an appropriate role to perform and an appropriate way of interaction in various social relationships, such as husband and wife (Bond, 1991; Cheung, 1996). Ng and Ng (2005, p. 13) contend that in a partnership in Chinese societies, ‘it is more accepted that the man is the more “interesting” half, the protector, and the woman the protected, who should be looking up to him’. So and Cheung (2005, p. 94) also point out that in Chinese culture ‘most sexual prescriptions were male-oriented, while the female took a passive role as a means of procreation’. Under such cultural influences, there is a widespread belief that wives' individual rights and interests should not be overemphasised, as this may harm the relationship with their husband. With a sense of inferiority, women often stay silent in face of men's sexual request. Second, according to the Chinese notion of self, behaviour is evaluated according to how well it serves to enhance harmony in interpersonal relationships. In this regard, Chinese women are used to avoiding open disagreement with their sexual partners for the sake of maintaining intimacy, even in the encounter of sexual violence (Chan, 2009). This may explain why young females often adopt a silent and passive role in contraception (Hong Kong Federation of Youth Groups, 1995).

Conceptual framework

In this qualitative study, the ‘Theory of Gender and Power’ is used to develop a conceptual framework for examining the power dynamics inherent in the negotiations of contraceptive use between adolescent sexual partners. The Theory of Gender and Power was introduced by Connell (1987), and has been viewed as providing a social constructionist framework to explore the process of psychosocial and cultural organisations of gender identities and sexual behaviours (Pulerwitz et al., 2000; Wingood & DiClemente, 2000). Connell points out three major structures that characterise the gendered relationships between men and women: the sexual division of labour, the sexual division of power, and the structure of cathexis. The sexual division of labour refers to the social structure that categorises what men and women should do in schools, families and labour markets. The sexual division of power refers to the power exercised by men in the form of capacity or right to repress women and to influence them. The structure of cathexis can be viewed as women's pursuit of deeper emotional closeness and bonding, causing women's greater emotional involvement in the romantic relationship (Tschann et al., 2002). Such an involvement may reinforce women to play a submissive role and uphold a sense of selflessness in sexual intercourse (Jewkes et al., 2001). While these three overlapping but distinct structures help explain the ways in which women's perception of sexual reality is shaped and sexual decision-making is guided, the present study focuses on the effects of the sexual division of power and the structure of cathexis on young females' perception and behaviour in relation to contraception.

By synthesising the Theory of Gender and Power, which investigates the structural factors of gender-based power imbalances, and the Social Exchange Theory, which examines the transactions of power between sexual partners, Pulerwitz et al. (2000, 2002) use the concept of sexual relationship power to explore how gender-based structural inequalities are manifested in sexual relationships, which in turn influence women's negotiations for safe sex. It refers to the resources that a person has available to influence his or her partner and the person's emotional involvement in the relationship. Although several attempts have been made to investigate the sexual relationship power and condom use negotiation of women (Pulerwitz et al., 2000, 2002; Teitelman et al., 2008), we know little about its applicability in Chinese societies. As the Theory of Gender and Power views sexuality as social conduct constructed by historical traditions, culture and societal norms, it is necessary to adopt a Chinese cultural perspective to study young adolescent females' sexual relationship power, and how it determines their negotiation of condom use.

Method

This research is a qualitative analysis of the lived experiences of young Chinese females in negotiating condom use with their male sexual partners. According to Tutty, Rothery, and Grinnell (1996), the mission of qualitative studies is to explore, interpret, and understand the social world, which is tightly connected with people's interests and with the rich meanings of their actions, thoughts, feelings, and events. Qualitative researchers aim to investigate a particular situation or event in which people have direct experiences they can describe as they took place in their life, and they search for the different levels of meaning produced by the subjective worlds of human beings (Smith & Osborn, 2003). Adding a gender and power dimension in analysing the narratives of the research participants (Willig, 2003), this study aims to examine the ways in which the power relations are produced in young females' condom use negotiations, explore the possibility of resistance inherent in the power relations, and analyse the structures of social norms and affective attachments that result in young females' acceptance of unsafe sex.

Research context and participants

According to the territory-wide survey conducted by the Family Planning Association of Hong Kong every five years since 1981, 13.2% of male respondents and 8.2% of female respondents in senior high school had experienced sexual intercourse in 2006 (The Family Planning Association of Hong Kong, 2006). This was a 3–5% increase as compared with the findings of the 2001 study. About 60% of males and 55% of females practiced contraception when they had sexual intercourse. Among the respondents, the male condom was used by 38% and 35.4% of young men and women, respectively (The Family Planning Association of Hong Kong, 2006).

The sample comprised 10 young females aged between 15 and 19. The majority of them had completed a junior high school education. Eight of them were service users of a district outreach social work team that provides counselling and guidance to young people, while two were recruited by one of the researchers in discos. All participants had undergone at least one experience of unplanned pregnancy at the time of data collection. Five of them had had two pregnancy experiences and one had had three. Regarding the most recent pregnancy, eight of them chose to undergo abortion and two chose to give birth. They were recruited by a snowballing method, as young pregnant females have been observed, both locally and overseas, to be a difficult group to reach (Hong Kong Federation of Youth Groups, 1995). The profile of the research participants is summarised in Table 1.

Table 1 Summary of the research participants' background information.

Name (pseudonym)	Present age	Age at most recent pregnancy	Result of most recent pregnancy	Duration of most recentpregnancy	Frequency of previous pregnancies
Mary	15	15	Abortion	3	0
Ann	16	15	Abortion	2	0
June	19	17	Abortion	4	1
Ivy	19	Unknown	Giving birth	Irrelevant	1
Betty	16	16	Abortion	4	1
Cindy	19	19	Abortion	1	1
Doris	19	18	Giving birth	Irrelevant	0
Eva	19	18	Abortion	3	2
Grace	17	17	Abortion	4	0
Helen	17	17	Abortion	Unknown	1

Data collection

The study used in-depth interviews for data collection, aiming to portray a comprehensive picture of the lived experiences of female adolescents in condom use negotiations. All interviews were conducted in private places, each lasting approximately 60–90 minutes. All interviews were taped with the written consent of the participants. A conversational style was maintained during the interview, with which the researchers engaged the participants and developed an empathetic understanding of their perceptions and experiences. While some guiding questions targeting the participants' own stories and personal perspectives were predetermined in the interview guide, flexibility was maintained by spontaneously setting up probes and follow-up questions (Rubin & Rubin, 1995). Questions were related to: their views on their sexual needs and the needs of their sexual partners; their thoughts and feelings on the functions of sexual behaviour; their attitudes towards sexual behaviour and contraception; their experiences of negotiating for sexual safety with their partners; and their perceptions of gender roles in sexual relationships.

Data analysis

After transcribing the narratives, the researchers began analysing the data. They read and re-read every line of the transcripts in search of ‘meaning units’ rather than relying on prior concepts to understand the data (Padgett, 2008). They then identified and labelled the themes by comparing and categorising the meaning units. Having refined the themes, the researchers began an advanced level of data analysis. In this phase a gender and power dimension was added to analysing the research participants' life stories (Willig, 2003). The researchers started to explore the participants' lived experiences, their actions, and behaviours as they pertained to the exercise of sexual relationship power. They then focused on examining the constitution of gender identities among the participants as well as their reactions in terms of compliance and resistance. Finally, they linked the themes with the social and cultural contexts. The trustworthiness was enhanced through a repeated cross-checking of the meaning units and themes selected from the stories of the participants. When a discrepancy arose between their understandings of the participants' lived experiences, the researchers kept exchanging opinions until agreements emerged.

Results

The following section examines the recurrent themes embedded in the stories of 10 young females who had experiences of unplanned pregnancy due to unprotected sexual behaviour. While their narratives revealed that each of them had a unique story, the repeated appearance of some messages showed an underlying attached meaning. Although most of the participants did not use terms such as gender and power, they used language relevant to these subjects when they recalled their valuable thoughts and feelings. The themes of their narratives reflect the power dynamics in condom use negotiations and the gender-based power structure that constitutes the young females' subjective world of sexual relationships. It should also be noted that the themes uncovered are not mutually exclusive. Rather, their co-existence can explain the complexity and multiplicity of the participants' lived experience.

Silence and passivity in condom use negotiations

While asking about the responsibility of having contraception in sexual intercourse, nearly all research participants expressed that both males and females have such responsibility. However, when their male sexual partners refused to use condoms, most of the participants tended to conform to their partners' sexual request and agreed to engage in unsafe sex. They said that it was difficult to explain why they could not take a more active role in birth control. The following reasons were given by June, Betty and Grace (pseudonyms were given to all research participants):

It is because my boyfriend requested not to use condom. Even though I had asked him to do so, he rejected. He did not care the risk of unsafe sex and he wanted to dominate in our sexual relationship. (Grace)

In fact, I asked him to use condom every time, but I could not reject him even he forced me to engage in unsafe sex because he was my boyfriend. I could do nothing when he insisted. (Betty)

I put all the blame for my pregnancy on my boyfriend. In fact, I knew I had the responsibility to take precaution, but as I could do nothing at that moment, what I could do was to blame my boyfriend. (June)

It is noteworthy that many participants asserted the equal responsibility between males and females to have protected sexual behaviour, but in reality they did not engage actively in safe-sex negotiations. Their narratives even imply that they did not think they had the right to make their own decisions about sexual activity. The following themes of the research findings may help us understand the reasons for their silence and passivity in condom use negotiations.

Power imbalance in condom use negotiations

Nearly all research participants touched upon the two dimensions of power imbalance in condom use negotiations. The first dimension of power imbalance was experienced as a form of oppression. It refers to the direct exploitation of the females' right to safe sex. The second dimension of power was operated through the passivity of the young females in the negotiation process. Both of them resulted in the male sexual partners' acquisition of power to make final decisions concerning contraception. June, Betty and Grace further talked about the influence of these two dimensions of power on young women's ability to negotiate for safe sex:

I don't have the right to make decisions. It is very unequal. He rejects using a condom! I could call it unfair. (June)

He invited me to watch a video at his home. When I arrived, he started to kiss me and wanted to have sex. I pushed him away, and he flirted with me. But I couldn't bear it. It was so painful that I burst into tears. Then he finished quickly. (Betty)

Interviewer	=	Do you take any precautions during sex?
Grace	=	Sometimes.
Interviewer	=	What method do you use?
Grace	=	Condom.
Interviewer	=	How often?
Grace	=	Most of the time we don't use it. He buys it when we need it. After that, he buys it only when I urge him to do so.

These narratives provide evidence of how the male sexual partners acquire the power to influence the young females to engage in unsafe sex. These accounts not only give a vivid illustration of the direct effect of power over the young females, but also indicate their exclusion from the decision-making process. No serious discussions had taken place between the participants and their partners on the matter of contraception. Even worse, when some participants tried to stop their partners from unprotected sex or initiated the use of condom, their partners simply neglected their requests or agreed to take precautions on limited occasions.

Resistance of young females against sexual partners' decision-making power

A first look at the stories resulted in a set of narratives in which research participants, caught inside power asymmetries, were powerless. However, a re-reading of their lived experiences revealed that some participants had tried to confront their partners. They remind us to avoid assuming that young females must be passive and suppressed by power while males must be active and control power. The following accounts reflect some participants' lived experiences:

I don't think it is possible to stop immediately when we are having sex, but I can decide whether to have it or not. I don't think someone is in the upper position and someone is in the lower position. I wouldn't do it if I didn't want to, but I would not use it to manipulate my partner. (June)

If I really want to take control, I will not give you control and I will hit you immediately if you touch me. If you really love me, you will stop when I say ‘no.’ In fact, I can sue you for rape if I don't want to have sex [and you force me]. (Cindy)

I will urge him to use a condom when he doesn't do so. If not, please walk away from me. (Helen)

Although the young females have a significant role to play in condom use negotiations in the face of power struggles with their sexual partners, one should be cautious about making a conclusion that their resistance can lead to a change in a gender-based power structure. In fact, when asked about whether they would reject the requests of their partners for having unprotected sex, many participants would tend to conform to their partner's will because they feared that the latter would be unhappy. Only two participants clearly claimed that they would say ‘no’ if their partners did not use condoms. In fact, any attempt to portray the power dynamics of condom use negotiations relying on oversimplified conceptions of power and resistance will inevitably lead to a distortion of the whole picture, due to leaving out the emotional dimension and the social construction of female sexuality.

Fulfilling sexual partners' needs by having unsafe sex

When considering condom use negotiations among adolescents, understanding young females' desire for maintaining a romantic relationship and achieving emotional intimacy with their partners is crucial. In the views of some research participants, fulfilling their partners' sexual needs is instrumental in preserving love and preventing them from dating other girls. They assume that males will regard females' willingness to engage in sex as an indicator of how deeply they love them. Therefore, young females may fear saying ‘no’ in order to ensure a stable relationship. The following narratives illustrate their perceptions and experiences:

Boys are different. Boys must have sex before they have love. They are very realistic. (Mary)

It is not me who has sexual needs, but I know that he has a lot of needs. I do this to prevent him from having sex with others. (Betty)

He couldn't feel my love. We quarreled yesterday. He said that I did little to attract him. I said: ‘go away!’ But I would cry if he went away. (Cindy)

He would burst with anger when I said ‘no.’ He would say, ‘All right, you don't love me’ or ‘you don't care about me.’ (Grace)

As perceived by Mary and Betty, it was natural for females to use unsafe sex to secure males' commitment to the relationship. Even though Cindy and Grace tried to reject their partners' sexual request, when their partners burst with anger and queried their love, they would give in finally. All of these narratives exemplify that the presence of resistance on the part of young females against the power of their sexual partners does not lead to an elimination of the gender-based power structure and dynamics in condom use negotiations. The research participants sought to maintain a good relationship with their partners and act in accordance with their partners' will. They avoid rejecting their partners or having disputes with them due to their fear of their partners' withdrawal from the relationship. Such a fear hindered them from participating in protected sexual behaviour and motivated them to give the decision-making power to their partners. For them, self-protection was subordinated to fulfilling the needs of their partners.

Young females' yearning for affective attachments

Besides fulfilling the needs of male partners, the romantic relationship has also been treated as the social arena where young females can attain deep emotional intimacy and meet their own sexual needs. Many participants' accounts show that they interpret having unsafe sexual intercourse as getting closer to their partners, which provides passion and ecstasy to both sides. The following are some typical examples of their interpretations:

I would see whether we had the right feeling and the feeling in communication. I would see whether I felt bored with him. I got close to boys easily in the past. I would have sex with them when they wanted. (June)

Love precedes sex. I am certain about that. I will not disagree if you say sex precedes love, but at least like the person. [Sex] can enhance the sense of intimacy and deepen the affection between two people. (Ivy)

I don't know, but it's necessary, which means it's impossible not to have it. But I don't know why it's so special. I just feel that if we really love each other, we'll have it. (Eva)

Helen	=	He said that he would feel more excited [without the condom], so I said I wouldn't do it. Then he said, ‘It's all right.’
Interviewer	=	Did you have any experience of having sex with him without using condoms?
Helen	=	Sometimes.
Interviewer	=	Why?
Helen	=	Sometimes when he doesn't feel happy, while sometimes when it feels good to do so.

The narratives show that the major determinant of unsafe sex is not the overt power asymmetries between adolescent females and their partners, but the strong desire of the former to achieve emotional intimacy and bonding with the latter. When one person wants to use a condom but the other does not, it is predictable that the one who has a higher attachment motivation will give in. For them, having safe sex is less important than securing affective attachments. Such a sacrifice is also seen as solid proof of love in their eyes.

It should be reiterated that when asking the research participants whether they were subordinated to the power of their male sexual partners in condom use negotiations, some participants expressed that neither had absolute power; some even recounted their experiences of fighting against their partners. However, in reality, all participants had engaged in unsafe sex, which had led to their pregnancy. In this case, power should not only be viewed as a force that creates repression between one party and another. It is also linked with the construction of gender identities that shapes the thoughts, feelings, actions and interactions of young sexual partners. In other words, there are different forms of power, overt and covert, conflictive and constitutive, that are demonstrated in the narratives of the research participants, with which a multi-layered understanding of the power structure and dynamics can be generated. In sum, sexual negotiation power is not only manifested via the subordination of women to men due to gender-based inequalities, but also maintained by the structures of social norms and affective attachments with regard to how young females construct their sexual identities.

Discussion

The findings of this research are consistent with results of relevant quantitative and qualitative studies, which explore and predict the contraceptive behaviour among adolescent females based on the gender and power perspectives of sexual relationships (Pulerwitz et al., 2000, 2002; Teitelman et al., 2008). The social construction of gender has been an important focus of related studies (Amaro, 1995; Gebhardt et al., 2003; Varga, 2003). Echoing the findings of those studies, this research suggests that although young females view themselves as having equal responsibility as males to engage in protected sexual behaviour, gender inequality is perpetuated by subtle power processes. The findings illustrate that young people who have greater sexual relationship power will get their way in terms of condom use, and young men seem to have greater sexual relationship power than young women (Blanc, 2001; Jewkes et al., 2001; Pettifor et al., 2004; Teitelman et al., 2008; Tschann et al., 2002; Varga, 2003). Furthermore, decision-making power is not as important as sexual relationship power in determining condom use among adolescents, because the degree of decision-making power is underpinned by the degree of sexual relationship power (Bowleg et al., 2000; Teitelman et al., 2008; Tschann et al., 2002). In other words, due to an asymmetrical sexual relationship power, females have greater difficulty of taking control over decision-making in condom use negotiations.

Recent research has suggested that it is not possible to understand the decision-making process regarding condom use without considering the power dynamics that emerge in sexual relationships among adolescents. Nevertheless, those studies put more emphasis on the overt and oppressive sides of power faced by young females. In their view, power is expressed via decision-making dominance, which refers to the ability to engage in behaviours against a partner's will or the ability to control a partner's behaviour (Bowleg et al., 2000; Pulerwitz et al., 2000; Teitelman et al., 2008; Tschann et al., 2002). The findings of this study indicate that the thoughts, actions, and interactions of young sexual partners may be governed by the covert and constitutive power, which diffuses in subtler and more effective ways in society (Connell, 1987; Wingood & DiClemente, 2000). Power can be manifested as a state of ‘false consciousness,’ which controls the minds and behaviours of young women and encourages them to follow the patriarchal ideology (Lukes, 1974). The narratives show that young women are taught to not assert their needs but are expected to fulfil the needs of their partners. If they confront their partners, they will be regarded as not performing typical sex roles. All of these factors illustrate the ways in which gender-biased messages are internalised in young females' beliefs, which causes them to become submissive and passive in condom use negotiations. Furthermore, power structures their sense of who they are and how they relate to their sexual partners (Foucault, 1990). The findings echo the Theory of Gender and Power, which states that young females' sexual behaviour is dictated by their yearning for emotional intimacy and sexual bonding with their partners (Connell, 1987; Teitelman et al., 2008; Wingood & DiClemente, 2000). Their sense of existence and feminine identity are built upon the romantic relationship. Sacrificing themselves to have unsafe sex is viewed as a proper way to remain in connection with their boyfriends. This form of sexual identity is constituted by the existing gender-based power structure and patriarchal ideology.

The narratives of the research participants also support the self-in-relation theories of women's development. According to Gilligan (1982) and Miller (1986), women's self, personhood and moral decisions are grounded in the motivation to preserve and enhance relationships with significant others. Young females may be preoccupied with the goal of achieving connectedness and avoiding conflicts with their sexual partners (Amaro, 1995; de la Cuesta, 2001; Pistole, 1999). They face a dilemma between bearing the risk of staying in unsafe sexual relationships and losing intimate bonding. Moreover, the degree of dilemma faced by young females varies according to culture and socio-economic status. While girls of higher education and socio-economic backgrounds are under great pressure to conform to the devalued feminine role, girls of lower education and socio-economic backgrounds are more vulnerable to the internalisation of an inferior gender identity in sexual relationships (Slater, Guthrie, & Boyd, 2001; Teitelman et al., 2008). As such, the target group of the present study is in urgent need of help. As Gilligan (1982) and Miller (1986) argue, young women should be facilitated to strike a balance between their own interests and those of their sexual partners. Through such a new understanding of the interrelationship between self and other, a sense of ‘mature love’ can be attained under the condition of preserving one's individuality and maintaining mutuality.

Culture provides the instructional guides for the collective life. Chinese culture perceives a person as a relational being, socially situated and defined in terms of the relationship system (To & Chu, 2009). Gender roles in Chinese culture are under the strong influence of its traditional beliefs and values. According to the teaching of Confucius, men and women should assume different roles and behaviours, and women should be subordinated to men (Bond, 1991; Cheung, 1996). Moreover, women are endowed with the ‘feminine’ virtues of sympathy and consideration, while men should develop ‘masculine’ traits such as dominance and aggression (Cheung, 1996; Ng & Ng, 2005). This cultural factor sheds light on gender differences between young women and their male partners regarding condom use, which is echoed by the findings of this study. However, the narratives also showed another side of the coin. While treasuring the sense of intimacy and bonding, some research participants tried to resist their partners' domination. Their behaviour can be explained by the hybridity of Chinese and western cultural values in Hong Kong society, which encourage Hong Kong citizens to be more aware of their individual rights and interests. This is in line with the results of recent research on the narrowing differences between Chinese and westerners on the perceptions of intimacy and connectedness with significant others (Han, 2002; Marshall, 2008; Tang & Dion, 1999). However, this does not mean that adolescent females would not unconsciously integrate the Chinese cultural values and gender stereotypes into their sexual behaviour and contraception practice (So & Cheung, 2005; To & Chu, 2009). The phenomenon should be understood as more complex and dynamic.

Implications for practice and research

Based on an over-simplistic view of power, the current notion of empowerment in advocating protective sexual behaviour and preventing adolescent pregnancy should be subjected to scrutiny, because it may overlook the complexity of gender and power with respect to sexuality. On the one hand, the concept of empowerment may be diluted, as helping professionals are more likely to apply empowerment-based ideas in micro-focused methods of intervention, such as enhancing young females' awareness of the adverse effects of unprotected sexual behaviour and educating them to ‘say no to unsafe sex’ (Blanc, 2001; Jewkes, Morrell, & Christofides, 2009). On the other, some attempts must be made to raise the consciousness of young women to address the structure of power and domination, and to mobilise them to engage in processes of fundamental personal and social transformations (Villaverade, 2008). However, despite truly understanding their inner struggles and supporting their efforts to make meaning of their own stories, practitioners could hardly co-construct the reflexive identities with young females, which refer to the synthesis of reflections and actions of young females in positioning themselves and dealing with the power structure of the patriarchal society (Brabeck & Brown, 1997; Worell & Remer, 2003). The goal of a practitioner is not to challenge the clients about their submissiveness and passivity, but to facilitate them to find more expanded personal narratives and interpretations, as well as more courage and capability to assert their needs and address their rights. For instance, practitioners can facilitate adolescent females to express their own perspectives on sexual relationships and use questions to facilitate their entrance into a process of critical reflection. They can also empower young females to reaffirm their strengths and competence to participate in safe-sex negotiations by noting ‘unique’ accounts or episodes that demonstrate exceptions to their beliefs and behaviours, helping develop an alternative and more preferred story about their sexual experience and decision-making (Bennett, 2008). In sum, gender-sensitive empowering approaches should be regarded as person-focused, collaborative and meaning-making practices (Brown, 2008).

In contrast with a technical and one-way transmission of knowledge and skills in promoting safer sexual behaviour, mutual aid is a panacea for encouraging mutual support and instilling hope among young females who encounter similar struggles. Many adolescent females, especially the ones of lower socio-economic backgrounds, can hardly find anyone to listen to their life struggles and thus feel themselves isolated (Slater et al., 2001). Therefore, a narrative approach to enhancing young females' awareness and ability in safe-sex negotiations should be launched through supportive group work. A group can set as a trustful platform for the girls to support and to learn from each other. The ones who have positive changes in their sexual experience and decision-making can share their life stories with other group members. Listening and responding to others' life stories can generate new insights in creating meaning in their own life struggles. They can also encourage each other to explore their own inner and social resources that had not been noticed before. The empowering effect can thus be exerted in a narrative-informed mutual support group.

As the findings show that men have a significant role to play in the decision-making process, intervention approaches that acknowledge the power relations in condom use negotiations should involve both young females and their male sexual partners. Relevant programmes and counselling services should help both sides to clarify their expectations of romantic relationships, understand their own sexual values and attitudes, achieve consensus on contraceptive use, facilitate positive gender-role development and ascertain gender-based inequalities and oppression. Moreover, assessing women's socialisation in a particular culture must include questions regarding the salience of gender as an organising principle within that particular cultural milieu (Brown, 1995; To & Chu, 2009). The findings of the study remind practitioners to be aware of the varieties of women's experiences and develop a multicultural, non-White and non-western approach to help young Chinese females to negotiate for sexual safety, while at the same time facilitate them to challenge the Chinese cultural values and beliefs that promote the subordination of women to men (Worell & Remer, 2003).

The ultimate goal of adding a power dimension in qualitative research is to take a critical stance challenging the dominant discourses and increasing the ‘voice’ of the marginalised (Willig, 2003). Following this line of thinking, the present study depicts the lived experiences of young females in condom use negotiations, whom are often labelled as ‘immoral’ and ‘irresponsible.’ Their own statements show that they are governed by the gender-based power structure, and that they should be regarded as a disadvantaged group that needs our care and support. More qualitative studies should thus be done to understand the stories of those young females. There is also a need to extend the research to exploring the views of young males on sexual relationships and contraception. Moreover, action research can be conducted. Through the co-construction of stories between the researchers and research participants, the consciousness of young females can be enhanced, and they can address the gender-based inequalities and oppression and engage in personal and social transformations.

Limitations of the study

This study is an exploratory study of the lived experiences of young Chinese females in condom use negotiations. Due to the small sample size of the study and the use of a snowball sampling method, the results cannot be generalised to the whole population. Furthermore, it focuses on young females who have experienced an unplanned pregnancy and who are at lower educational levels. It is questionable whether young females with higher educational levels and different social backgrounds share the same or similar experiences. Future studies of a broader cross-section and a diversity of young females would definitely increase our understanding of this research topic. Interviews with young male sexual partners can also be conducted to capture the discrepancies of the narrations between them and those of young females.

Additional information

Notes on contributors

Siu-ming To

Siu-ming To is an assistant professor in the Department of Social Work at the Chinese University of Hong Kong. His research interests focus on youth services and youth work practice, family education, school social work, qualitative research methodology, and programme evaluation.

Hau-lin Tam

Hau-lin Tang is an instructor in the Department of Social Work at the Chinese University of Hong Kong. Her research interests include service for young people, group and community work, youth empowerment, postmodernism and social work.

Fung Chu

Fung Chu is a service development officer in the Caritas Youth and Community Service in Hong Kong. He has been providing youth service for nearly 15 years. He has also been engaging in studies related to youth service, youth work practice, sexuality, and substance abuse.