Journal of Adolescent Health 64 (2019) S52eS58

www.jahonline.org

Review article

Adolescent Sexual Risk Behavior in Hong Kong: Prevalence,

Protective Factors, and Sex Education Programs
Hildie Leung, Ph.D. *, and Li Lin, Ph.D.
Department of Applied Social Sciences, The Hong Kong Polytechnic University, Hong Kong, PR China

Article history: Received June 12, 2018; Accepted December 4, 2018

Keywords: Risky sexual behavior; Positive youth development; Sex education; Sexual health; Chinese adolescents

A B S T R A C T
IMPLICATIONS AND
CONTRIBUTION
Although Hong Kong is considered to be a relatively westernized Chinese society, sex remains to be a
subject that is rarely discussed openly. This article provided a brief overview on the prevalence of
This review revealed that
sexual behaviors and attitudes among adolescents in Hong Kong. Compared with the West, Hong the effectiveness of sex
Kong adolescents are less sexually active; however, increasing rates and more liberal sexual attitudes education programs in
have been reported over the decades. These worrying trends have caused great concern and begged Hong Kong remains limited.
the question of occurrences and the effectiveness of sex education programs. Endeavor has been To enhance effectiveness,
made to identify protective factors for reducing adolescent risky sexual behaviors and promoting more evidence-based, posi-
sexual health from a strength-based perspective, such as the positive youth development (PYD) tive youth-centered, partic-
approach. However, to date, there is little synthesis of empirical evidence in the literature on the ipatory approaches may be
relations between PYD and adolescent sexual behaviors. We attempted to fill in this gap by outlining adopted. Programs should
empirical evidence on the protective roles of PYD attributes in youth sexual outcomes. We reviewed be multilevel to include
local sex education programs and outlined several observations regarding foci, implementation, and peer and parent compo-
evaluation. To conclude, we provided suggestions to inform practice in the future development and nents. Innovative imple-
implementation of sex education programs to promote sexual health among youths. mentation strategies using
Ó 2018 Society for Adolescent Health and Medicine. All rights reserved. digital and social media
to engage youths are
encouraged.

Hong Kong is regarded as the most westernized Chinese so-
ciety presumably because of its history of British colonization. Yet,
the topic of sexuality, if not a taboo, at least, in general, is still not as
openly expressed or discussed as in Western countries [1,2].
Emerging research has pointed to a worrying trend in adolescent
sexual behavior and sexual education in Hong Kong [3], calling for
research on protective factors and effective sexual education that
Conflicts of interest: The authors have no conflicts of interest to disclose.
The authorship is equally shared by Hildie Leung and Li Lin.
Disclaimer: Publication of this article was supported by the Hong Kong Poly-
technic University. The opinions or views expressed in this article are those of
the authors and do not necessarily represent the official position of the funder.
* Address correspondence to: Hildie Leung, Ph.D., Department of Applied
Social Sciences, The Hong Kong Polytechnic University, Hung Hom, Kowloon,
Hong Kong, PR China.
E-mail address: hildie.leung@polyu.edu.hk (H. Leung).
can successfully use these protective factors to improve adoles-
cents’ sexual health. In this review article, we briefly summarized
the prevalence of sexual behaviors and attitudes among adoles-
cents in Hong Kong, discussed the protective factors of early and
risky sexual behavior within a strength-based viewdpositive
youth development (PYD) perspectivedreviewed local sex edu-
cation programs (i.e., foci, implementation, and evaluation), and
finally pointed out the future direction of related research and
sexual education in Hong Kong.
Prevalence of Adolescent Sexual Risk Behaviors
Hong Kong people usually have relatively conservative atti-
tudes toward sexuality [4], and Hong Kong adolescents are not as
sexually active as their Western counterparts. Madkour et al.’s [5]

1054-139X/Ó 2018 Society for Adolescent Health and Medicine. All rights reserved.
https://doi.org/10.1016/j.jadohealth.2018.12.007
 H. Leung and L. Lin / Journal of Adolescent Health 64 (2019) S52eS58
study on 15-year-olds from five Western countries (the United
States, Scotland, Finland, France, and Poland) found that the
prevalence rate of sexual intercourse ranged from 18.1% (Finland)
to 33.1% (Scotland). However, in Hong Kong, only 3.4% of
adolescents (aged 10e19 years) reported having experience of
sexual intercourse [6]. According to the results of the survey
conducted by the Family Planning Association of Hong Kong [3]
on youth sexuality every 5 years, in the assessment of 2016,
among middle school students (Grades 7e9), about 1% and 2% of
girls and boys reported having sexual intercourse, respectively,
whereas these numbers were 6% and 7% among high school
students (Grades 10e12).
However, Hong Kong adolescents have become increasingly
liberal in sexual attitudes and active in sexuality-related behavior
in the past decades. The Family Planning Association of Hong
Kong (FPAHK) [3] revealed that compared with the 1991 cohort
(first assessment), more respondents of the 2016 cohort of high
school students (Grades 10e12) regarded having multiple sex
partners (females: 8% vs. 9%; males: 21% vs. 24%), premarital sex
(females: 26% vs. 37%; males: 46% vs. 51%), and cohabitation
(females: 52% vs. 69%; males: 59% vs. 76%) to be acceptable. In
addition, it is easy for Hong Kong adolescents to access porno-
graphic materials. According to Chung et al.’s [7] study on stu-
dents in the 8th to 10th grades, about 80% of the adolescents
reported having the experience of accessing sexually explicit
online materials with 7.6% as frequent users.
Sexual initiation during adolescents is deemed problematic,
especially in Chinese societies, as unintended pregnancy and
sexually transmitted infections are likely to happen with the
sexual intercourse at younger ages [5]. This concern is not
uncommon in Hong Kong as sexual knowledge of Hong Kong
adolescents is found to be inadequate [8]. The FPAHK [3] revealed
that, on average, high school students (Grades 10e12) had
accurate responses to three fourth of sexual knowledge ques-
tions on birth control, sexually transmissible diseases, and
HIV/AIDS, whereas middle school students (Grades 7e9) got less
than half of the questions correctly. In addition, among those
having sexual experience, the occurrence of risky sexual
behavior is high. Lee and Tsang’s [6] study found that less than
half of adolescents who had sexual experience used a contra-
ceptive device during sexual intercourse. Early sexual initiation is
not beneficial because it is related to psychosocial maladjust-
ment. In Hong Kong, adolescents with sexual experience were
more likely to have other emotional problems (e.g., depression)
and behavioral problems (e.g., binge drinking [9]), and even
suicidal behavior [10].
Protective Factors of Adolescent Sexual Behavior
Emerging endeavor has been made to identify the protective
factors that reduce the occurrence of adolescent (risky) sexual
behavior from a strength-based view. Understanding these pro-
tective factors enables practitioners to design and implement
appropriate sex education programs that help improve adoles-
cents’ understanding about sexual behavior and their capacities
of disengaging from early and risky sexual behavior. In this
section, we briefly discussed protective factors of sexual behavior
within a strength-based viewdPYD perspectivedwhich calls for
more focus on adolescents’ potentials and capacities than their
problems and deficits in their development [11]. PYD can be
manifested in adolescents’ competence (e.g., cognitive compe-
tence and social competence), confidence (e.g., high self-worth),
S53
character (e.g., internal standards for right behavior), connection
(e.g., positive bonding with healthy peers and adults), and caring
(e.g., empathy and compassion toward others [11]). One of the
major propositions of the PYD perspective is that enhancing PYD
may protect adolescents from engaging in risk behavior [11,12].
Adolescents with greater PYD are more capable of coping with
developmental challenges in an effective way. They may be more
competent to handle stress rather than externalizing it into
problematic sexual behavior, more confident to reject unwanted
or unsafe sexual behavior, have more social network with sup-
portive adults from whom they can seek help, or have a higher
aspiration and more positive outlook for future, which probably
defer their sexual initiation [13]. In this tenet, adolescents with
higher levels of PYD are less likely to engage in risky sexual
behavior.
Empirical research testifying this proposition is mounting in
the Western academia. In 2010, Journal of Adolescent Health
published a special issue [14], which reviewed the evidence of
the positive role of PYD attributes (i.e., competence, confidence,
connectedness, and character) in adolescent sexual and repro-
ductive health (ASRH) outcomes (e.g., condom use, contraception
use, pregnancy, and sexually transmitted infection). The review
on competence attributes [15] concluded that adolescents’
academic competence might defer their sexual initiation and
increase their contraceptive use, and their social/behavioral
competence (i.e., communication skills) may prevent them from
undesirable ASRH. Also, confidence attributes (i.e., belief in the
future and self-determination) [16], connectedness attributes
(family connectedness, parentechild communication, parental
monitoring, partner connectedness, and school connectedness),
[17] and prosocial norms and spirituality [18] all serve as pro-
tective factors of undesirable ASRH.
In contrast with the heated discussion in Western academia,
related research in Hong Kong lags far behind. The literature
search using “Hong Kong,” “sexual behavior,” and “positive youth
development” as a topic resulted in only two articles from
journals with Social Sciences Citation Index. These two longitu-
dinal studies implied a positive role of PYD in Hong Kong
adolescents’ sexual behavior. When assessing PYD in terms of 15
constructs (i.e., bonding, resilience, social competence,
emotional competence, cognitive competence, behavioral
competence, moral competence, self-determination, spirituality,
self-efficacy, clear and positive identity, belief in the future,
recognition for positive behavior, opportunities for prosocial
involvement, and prosocial norms [19]), Shek [20] found that
adolescents’ overall PYD levels at Grade 7 were negatively
associated with their sexual behavior and intention to engage in
sexual behavior at Grade 9, implying that PYD prevents adoles-
cents from active sexual behavior. Shek and Leung’s [21] further
study also found that the overall PYD level was negatively
associated with sexual behavior at Grade 7, but it was not related
to the increasing trend of sexual behavior over the six high school
years.
Additional evidence comes from research investigating
singular PYD attributes in the domains of connectedness and
character. Lam et al. [22] found that with more family involve-
ment, adolescents are less likely to engage in sexual intercourse,
whereas those who engage in sexual activity tend to have less
satisfactory relationships with their parents. However, they also
found that social support increased the likelihood of sexual
intercourse, and they considered that social support could
derive from various sources, which may not be equally
S54 H. Leung and L. Lin / Journal of Adolescent Health 64 (2019) S52eS58
protective. In a sample of colleague students, Chan and Cheung
[23] revealed that their permissive attitudes toward premarital
sex and perceived permissive norm increased their intention to
engage in premarital sex, which suggests that character plays a
role in it.
Although the current studies in Hong Kong support the
protective role of PYD in adolescent sexual behavior, whether
PYD can minimize ASRH outcomes of Hong Kong adolescents is
far from conclusive because of limited evidence. Further studies
are especially needed to identify which PYD attribute(s) are most
effective in reducing risky sexual behavior. In addition, based on
the assumption that adolescent sexual behavior is risky, the
existing investigation of sexual behavioral outcomes is limited to
the occurrence of sexual intercourse, with little effort to differ-
entiate safe sexual behavior from risky sexual behavior. Yet, risky
sexual behavior probably leads to more harmful outcomes
compared with safe consensual sexual activities in adolescents,
thus requires a differential investigation.
Sex Education
In the present article, sex education broadly encompasses
educational programs and interventions across school, family,
and community contexts. In Hong Kong, besides formal educa-
tion in school, there are also programs and activities that are
developed and administered by government bureaus and local
organizations (see Table 1). Sex education has been defined as
education that recognizes and promotes human rights, gender
equality, knowledge, values, and skills crucial for sexual health
and the prevention of HIV [24]. We follow Naezer et al.’s [25]
broader conceptualization of sex education as “sexual knowl-
edge building” so as to encompass more than sexual-related
facts, but rather, the entire repertoire of information that
individuals acquire about sexuality. By adopting the concept of
“sexual knowledge building instead of sex education is useful for
broadening our understanding of sexual learning as a process
that also takes place outside the context of teacher-led, school-
based, formal education” [25].
Sex education in Hong Kong commenced in the 1950s pre-
dominantly by the works of the Family Planning Association,
focused on fertility control and contraception. It was only in 1971
that the Education Department issued a memorandum to schools
advising them to incorporate sex education topics in the school
curriculum. This was followed by subsequent guidelines pub-
lished in 1986 and 1997 on specific topics, resources, and refer-
ences aiding the implementation of sex education. Despite the
efforts to integrate sex education into the primary and secondary
education curriculum in Hong Kong, its effectiveness is limited
and has been criticized for several reasons [26]. First, the advised
content to be delivered to junior secondary school students
pertained more to “life education” than “sex education” per se.
Second, the guidelines are heavily biased toward indoctrinating
socially accepted moral values and focused mainly on emotional
well-being, self-images, and human relationships. Discussions on
sexual behavior and psychology, sexual variation, prostitution,
and pornography were limited [27]. Third, Wong [28] com-
mented that sex education in Hong Kong high schools is merely
an attempt to control sexual expression.
At present, a permeated approach is still adopted, where
suggested topics are included within moral and civic education
classes as stipulated by the Education Bureau. With no formal
curriculum, schools lack well-established sex education
programs, and teachers tend to perceive them as subsidiary,
being a nonexaminable subject [29]. A recent survey of 134
secondary schools found that the implementation of sex educa-
tion at junior level of secondary schools remains inadequate. On
average, a school spent merely 3 hours each academic year on life
skills-based education related to HIV/AIDS or sex. Schools re-
ported barriers including the lack of time, low priority, not
treating this subject matter as an explicit learning objective, lack
of documented policy, teaching and learning resources, and
teachers’ training [30]. Yet, few mandatory subjects are dedi-
cated specifically to sex education. Yu [31] concluded that sex
education in Hong Kong schools is “still as lousy as it was years
ago” (para. 11). This causes serious concern, as a recent study on
over 500 adolescents and young adults (aged 12e24years) in
Hong Kong examined the source of information about sex and
found that, in fact, 29% of the respondents had learned about sex
from their school teachers, whereas, 27% have obtained infor-
mation about sex from the media, 20% from their peers, and only
4% from their parents or elder relatives [32].
At home, because of traditional Chinese values, discussions
surrounding the topic of sexual behaviors are also limited. Lau
[32] reported that 77% of respondents’ parents had never spoken
to them about sex. Among parents who have, it was done so
infrequently, that is, every 6 months to 1 year. Lai [33] inter-
viewed Hong Kong parents regarding their perceptions on sex
education for preschool children and found that majority of
parents lacked confidence and felt uncomfortable to engage in
sex-related discussions with their children because of insuffi-
cient knowledge and communication skills. In fact, there are
family sexuality education targeted to equip parents with
sex-related knowledge, attitudes, communication skills, and
confidence in teaching so as to encourage parents to educate
their children at home regarding issues on sexuality and self-
protection. Various programs such as parentechild activity
days and workshops for parents are held regularly by nongov-
ernmental organizations such as the Family Planning Association
of Hong Kong [3].
In addition to family sexuality education, the Association [3]
also conducts community-based sex education programs aimed
to raise public awareness of sexual and reproductive health.
These activities include sex life talks, exhibitions, video show-
ings, game booths, and mobile classrooms. Moreover, public
events to promote sexuality education is held such as the Hong
Kong Sex Cultural Festival and Sexuality Education Conference
on Adolescents Sexual and Reproductive Health.
Foci of sex education programs
The foci of sex education programs in Hong Kong can be
categorized into two main strands: namely, sexuality education
and preventive sexual abuse education. Under the umbrella of
sexuality education programs, first, most programs focused on
disseminating knowledge regarding sexually transmissible
infections and prevention. Second, there are programs that
encourage a heterosexually envisaged future [34], such as the
Project Touch, which targeted to minimize school bullying
related to sexual orientation by enhancing students’ knowledge
on sexual orientation and fostering values of respect and culture
of diversity. Third, there are programs that promote stable family
life, prevention of promiscuity, and unplanned pregnancies [34].
These programs are developed to nurture positive values and
attitudes regarding love, relationships, and marriage to enhance
 H. Leung and L. Lin / Journal of Adolescent Health 64 (2019) S52eS58
Table 1
Sex education programs in Hong Kong
Program title Organization
Life-Skills Based Education (LSBE) Programs on The Family Planning
HIV/AIDS and Sex Association of Hong
Kong (FPAHK) and Red
Ribbon Centre,
Department of Health
School Sexuality Education Integrated Program FPAHK
FPA Jockey Club Teen Bean Mobile Classroom FPAHK
Youth Sexual-Health Education Training AIDS Concern
Program
“Love and Loyalty” Integrated Education Caritas Integrated Family
Scheme Service Centre
The ECSAF Sex-Abuse Preventive Program End Child Sexual Abuse
Foundation
The ECSAF Sex-Abuse Preventive Program End Child Sexual Abuse
Foundation
The Hong Kong Sex Cultural Festival Hong Kong Sex Education
Association and FPAHK
Sex Education Workshop The Society for Truth and
Light
Resource Centre Visit The Society for Truth and
Light
General Love Relationship Education e Primary The Hong Kong Federation
and Secondary School Love Relationship and of Youth Groups
Sex Education Program
“Get to Know Different Sexual Orientation: The Boys’ & Girls’
Collaboratively Build a Harmony Campus” Association of Hong
Workshop Series Kong
Integrated Activities on AIDS and Sex Education Hong Kong Aids Foundation
for Youth
General Sex Education Workshop Mother’s Choice
“Sexual Health and Drug Abuse” Healthy Community Health
Workshop Organization for
Intervention Care and
Empowerment Limited
Mask Design Contest and AIDS Walk The Society for AIDS Care
Adolescent-Oriented Life Skills Education The Society for AIDS Care
Program
S55
Domain Intended learning outcomes
SE - To increase students’ knowledge on sex and safe sex
- To raise students’ awareness on HIV/AIDS
http://www.rrc.gov.hk/res/practice/15_3eng.pdf
SE - To increase public knowledge and awareness on sex
https://www.famplan.org.hk/sexedu/b5/event/event_details.
asp?evid¼219
SE - To increase public knowledge on sex
- To increase public awareness on HIV/AIDS
https://www.famplan.org.hk/sexedu/B5/training/training_
details.asp?trID¼50
SE - To increase public knowledge on sex
- To nurture future sexual health educators
- Youth empowerment
http://webcontent.hkcss.org.hk/cy/YSE%20Training_Nov2010/
PDF/AIDS%20Concern.pdf
SE - To increase students’ knowledge on sex
- To address love and loyalty in relationships
https://family.caritas.org.hk/zh-hk/services/view/69#.
WcIgbcgjGUl
SAP - To prevent sexual abuse
- To increase students’ knowledge on sex
- To deliver positive values and attitudes on sex
http://www.ecsaf.org.hk/English/work.php?expandable¼1&mid
2¼3&mid¼2
SAP - To increase students’ knowledge on sex
- To raise students’ awareness of sexual abuse
- To prevent sexual abuse
http://www.ecsaf.org.hk/English/work.php?expandable¼1&mid
2¼3&mid¼2
SE - To increase public knowledge on sex
- To offer a public platform to discuss about sex
https://hksea.wordpress.com/
SE - To increase students’ knowledge on sex
- To deliver positive values and attitudes on sex
http://www.truth-light.org.hk/myimage/files/myform/latest_
form/sexedu_workshop_topic_2017b.pdf
SE - To increase public knowledge on sex
- To deliver positive values and attitudes on sex
http://www.truth-light.org.hk/visit_center
SE - To increase public knowledge on sex
- To deliver positive values and attitudes on sex
http://ssw.hkfyg.org.hk/page.aspx?corpname¼ssw&i¼2516
SE - To prevent bullying related to sex orientation
- To increase students’ knowledge on sex orientation
http://www.newtouch.net/school_workshop.html
SE - To increase youth knowledge on sex and safe sex
- To deliver positive values and attitudes on sex
- To increase public knowledge on HIV/AIDS and de-stigmatize
people living with HIV/AIDS
http://aids.org.hk/?page_id¼2828&lang¼zh#1484043461323-
211a1169-730d
SE - To deliver positive values and attitudes on sex
- To prevent youth accidental pregnancy
http://www.motherschoice.org/what-we-do/for-youth/
book-a-sexuality-education-workshop/
SE - To increase public knowledge on sex and sexually transmitted
disease
- To deliver positive values and attitudes on sex
http://www.communityhealth.org.hk/new/service_4.php
SE - To increase the public knowledge on sex and HIV/AIDS
- To de-stigmatize people living with HIV/AIDS
http://www.aidscare.com.hk/en/index.php?page¼education#s2
SE - To increase the public knowledge on sex, safe sex and HIV/
AIDS
- To reduce the prevalence of HIV/AIDS
http://www.aidscare.com.hk/en/index.php?page¼education#s3
(continued on next page)
S56 H. Leung and L. Lin / Journal of Adolescent Health 64 (2019) S52eS58
Table 1
Continued
Program title Organization
Education Talk, Public Education & Program The Society for AIDS Care
“Red Ribbon in Action” AIDS Education Funding Red Ribbon Centre
Scheme
The Positive Energy (POZ) in the City AIDS Concern
Making Smart Choices Family Planning
Association
Faculty of Education,
University of Hong Kong
SAP ¼ sexual abuse prevention; SE ¼ sexuality education.
students’ awareness of risks associated with premarital sex and
compensated dating.
In terms of sexual abuse prevention programs, the End Child
Sexual Abuse Foundation has developed a comprehensive pro-
gram targeted for local primary and secondary school students.
The Program aimed to help students develop proper attitudes
toward sex and provide information and skills on protection from
sexual abuse.
Modes of implementation
Regarding modes of implementation, majority of the pro-
grams adopted the traditional class-based approach through
conducting lessons, talks, or workshops, a wide range of inter-
active activities were designed to engage students. These include
role-plays, value reflections, in-depth discussions on sex-related
issues, demonstrations on condom use, and sharing by invited
speakers such as people living with HIV/AIDS. Out of classroom
activities such as book fairs, exhibitions, walks, design compe-
titions are also conducted in the community.
Recently, practitioners have adopted more interactive
approaches to promote sex education. Rather than merely con-
ducting lectures in traditional classroom settings, Chu et al. [35]
adopted a game-based, participatory learning approach in the
development of an interactive game “Making Smart Choices”
where students engaged in minigames such as role-playing
virtual character on smartphones, iPads, and social media.
Program evaluation
Although local organizations that have developed a range of
sex education programs for children and adolescents, most
programs lacked evaluation. Only few programs had published
evaluation findings in their annual reports or official Web sites.
Regarding methodology, subjective outcome evaluation strategy
that focused on examining participants’ perceived satisfaction
with the program or whether they perceived the program to be
beneficial to them was used. For instance, evaluation on a Sexual
Abuse Preventive Program was conducted by asking teachers
whether they perceived the facilities in the mobile classroom,
the design of the program, and performance of education officers
as satisfied, fair, or unsatisfied. Results showed that more than
90% of teachers were satisfied with the different attributes of the
Domain Intended learning outcomes
SE - To increase teenagers’ knowledge on HIV/AIDS and safe sex
- To de-stigmatize people living with HIV/AIDS
http://www.aidscare.com.hk/en/index.php?page¼education#s4
SE - To increase teenagers’ knowledge on HIV/AIDS and safe sex
- To de-stigmatize people living with HIV/AIDS
- To encourage public to implement educational activities about
HIV/AIDS
http://www.rrc.gov.hk/english/action.htm
SE - To increase teenagers’ knowledge on HIV/AIDS and safe sex
- To de-stigmatize people living with HIV/AIDS
http://aidsconcern.org.hk/services/#services-education
SE - To enhance adolescents’ greater knowledge and awareness
about sexually transmitted infection prevention
- To promote knowledgeable decision-making regarding
healthy sexual practices
program [36]. Qualitative strategies were also used in the eval-
uation of a love and sex education program by the Hong Kong
Federation of Youth Groups [37], where youths provided written
feedback on their perceptions (e.g., feelings) after participating in
an interactive workshop.
Indeed, there was a lack of published studies in journal
articles regarding the evaluation of the identified programs. An
exception is Chu et al.’s [35] evaluation study on the effectiveness
of an interactive sex education game application “Making Smart
Choices” in which both quantitative and qualitative strategies
were used. In terms of objective evaluation, the authors adopted
a pre- and post-test design to examine whether participating in
the program enhanced students’ knowledge of safe sex. Students’
subjective feedback regarding the perceived value and effec-
tiveness of the game-based program was also gauged through
questionnaires and focus groups. Findings showed a significant
improvement in sexual knowledge among program participants.
They also reported the program to be interactive, interesting, and
related to their lives.
Program evaluation is important as a systematic collection of
empirical data to provide evidence on the effectiveness of the
program. Rigorous evaluations of sex education should involve
both quantitative and qualitative, as well as cross-sectional and
longitudinal methodologies to understand the mechanisms
through which programs exert effect on youths and social change
[38]. In addition, we may need rigorous assessments of youth’s
behavioral outcomes (e.g., unprotected sex activity) in quanti-
tative and qualitative evaluation.
Implications
The liberal sexual attitudes embraced by Hong Kong adoles-
cents nowadays as evidenced by the increasing percentage of
high school students reporting premarital sex, cohabitation, and
having multiple sex partners as being acceptable [3] pose serious
risks for adolescents and the society (e.g., teenage pregnancy and
sexually transmitted diseases). To alleviate these problems, Shek
et al. [39] proposed that long-term quality education, especially
sex education in schools should be implemented.
Yet, sex education in Hong Kong is currently insufficient.
Considering sexuality-related knowledge of Hong Kong young
people is inadequate, especially contraceptive knowledge [40],
we recommended that sex education programs should
 H. Leung and L. Lin / Journal of Adolescent Health 64 (2019) S52eS58
emphasize knowledge in contraception and highlight the nega-
tive consequences associated with liberal attitudes toward pre-
marital sex and high-risk sexual behaviors. However, having
knowledge does not guarantee healthy sexual development.
Recently, scholars have adopted a more holistic approach to
studying sexual health, defining it as a state of physical, mental,
and social well-being in relation to sexuality, as opposed to
merely the absence of dysfunction or infirmity [41]. Harden [42]
advocated the adoption of a pro-sex positive framework for
research and practice on adolescent sexuality that contrasted
traditional risk perspectives, which have abstinence at their core.
It is argued that consensual sexual activities during adolescence
are developmentally normative. This perspective is supported by
Western studies which evidenced the potential benefits of sexual
behaviors to youths’ physical, mental, and social health [43]. For
instance, European sex education such as Dutch school-based sex
education programs is known for its comprehensive and liberal
approach, where sex is considered a part of everyday life that
should be celebrated. However, debates on whether the Dutch’s
empowerment approach to sex education remains in conflict
with countries may be dominated by more conservative moral
views [25]. As observed by Kwan et al. [44], “despite the socio-
logical changes, sexual issues essentially remain a taboo in Chi-
nese society” (p. 18). Indeed, the United Nations Population Fund
[45] highlighted that one of the operational guidance for the
effective implementation of comprehensive education is the
importance of focusing on the social context. Cultural appropri-
ateness, that is, programs tailored for distinct populations, are
needed. As such, further evidence is needed in a Hong Kong
context to identify a sex education approach that is culturally
appropriate.
We propose that rather than adopting a “deficit-based”
approach, PYD approach that focuses on the promotion of
developmental assets, potentials, and abilities of adolescents
should be adopted in Hong Kong. Catalano et al. [13] advocated
PYD as an approach to promote ASRH. Maas and Lefkowitz [46]
also contended that a PYD framework should be used to under-
stand how PYD constructs serve as protective factors to promote
healthy sexual development among adolescents. Researchers
also recommended new strategies to promote adolescent sexual
health such as empowering young people and building agency
[47]. Furthermore, in addition to equipping adolescents with
intrapersonal and interpersonal competencies, intervention
programs to promote sexual health need to include components
addressing specific physiological factors such as hormonal
changes and brain development, as these changes are inevitable.
It is crucial to guide adolescents to be aware of and understand
how these physiological changes may impact and interact with
their peer and social relationships and to help them weather
through their puberty [48].
Few of the sex education programs in Hong Kong had
incorporated family components in the program despite evi-
dence suggesting the effectiveness of family involvement in
school comprehensive sex education program [49]. Lau [32]
echoed the need for Hong Kong parents to play a more active
role in children’s sex education starting at an early age. He
urged for policy efforts to raise parents’ awareness on the
importance of sex education at home and to cultivate an envi-
ronment in which sex is not a taboo, but a topic that can be
freely discussed. Modeling from practices in the West, programs
may enhance parents’ comfort and competence by equipping
them with adequate knowledge, structured guidelines, and
S57
resources to communicate with their offspring on sex-related
topics [49]. For example, programs can help parents to learn
how to communicate with their teens about puberty knowledge
and respond to their puzzle about puberty.
Furthermore, despite the rise of sex education in Hong Kong,
these programs commonly lack rigorous research that examines
the program effectiveness. “Good evaluations of sex and rela-
tionship education involve employing prospective, descriptive
studies (both quantitative and qualitative, and both longitudinal
and sectional) with the aim of understanding the mechanisms
through which entire programs (rather than one-off in-
terventions) effect (or fail to effect) social change” [38]. Gener-
ally, two types of evaluation are needed, including the
summative evaluation that demonstrates the program benefits
and outcomes and the formative evaluation that investigates the
program process and performance. Sex education professionals
may need to integrate these evaluations in the future program
implementation so as to understand what cause the desirable
outcomes and how to improve the practices.
Against the insufficient state of sex education in Hong Kong, it
is suggested that more evidence-based, positive youth-centered,
participatory approaches may be adopted in future sex education
programs. Programs should be multilevel to include peer and
parent components. Modern implementation strategies such as
the use of digital and social media to engage youths are
encouraged. Finally, rigorous evaluation research should be
conducted for the sake of sustainability of sex education.
Supplementary data
Supplementary data related to this article can be found at
https://doi.org/10.1016/j.jadohealth.2018.12.007.
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